UM RN - Behavioral Health

The UM RN - Behavioral Health supports members by coordinating high-quality behavioral health services and ensuring appropriate access to care through utilization management practices. The role combines clinical expertise, care coordination, and evidence-based decision-making to improve member outcomes.

Accountabilities

• Evaluate, coordinate, and manage behavioral health services while ensuring appropriate utilization of healthcare benefits.
• Collaborate with members, providers, and internal teams to support effective care planning, regulatory compliance, and positive health outcomes.
• Perform prospective, concurrent, and retrospective utilization reviews for inpatient, outpatient, ambulatory, and ancillary behavioral health services.
• Assess medical necessity, appropriate levels of care, treatment duration, and service intensity using established clinical criteria and guidelines.
• Review and process authorization requests, including elective, urgent, emergency, direct, and ancillary service requests.
• Collaborate with providers, facilities, and healthcare professionals to identify appropriate treatment options and alternative care solutions.
• Develop, coordinate, and communicate discharge planning activities with internal and external stakeholders.
• Research and resolve issues related to benefits, eligibility, unauthorized services, coordination of benefits, and member care needs.
• Analyze and prepare documentation for retrospective reviews, appeals, and regulatory requirements.
• Communicate with members, providers, and other stakeholders to facilitate effective treatment planning.
• Provide education to provider communities regarding policies, procedures, benefits, and utilization management practices.
• Identify opportunities to improve healthcare quality, service effectiveness, and benefit utilization.
• Support additional departmental responsibilities as needed.

Requirements

• Licensed registered nurse with behavioral health experience and a strong understanding of utilization management processes.
• Demonstrates clinical expertise, regulatory awareness, and effective communication with diverse healthcare stakeholders.
• Minimum of 2 years of acute clinical nursing experience and at least 1 year of behavioral health clinical experience.
• Experience in managed care, utilization management, or health insurance environments preferred.
• Case Management certification or progress toward certification is highly preferred.
• Strong knowledge of medical necessity criteria, clinical guidelines, and healthcare service levels.
• Understanding of current nursing practices, behavioral health trends, alternative care settings, and treatment approaches.
• Knowledge of healthcare policies, procedures, member benefits, community resources, and applicable regulations.
• Familiarity with accreditation standards such as NCQA and healthcare compliance requirements.
• Excellent written and verbal communication skills.
• Strong interpersonal, problem-solving, and customer service abilities.
• Proficiency with Microsoft Office applications and remote communication technologies.
• Ability to work effectively across multiple time zones in a remote environment.

Benefits

• Competitive annual salary range of $65,000 - $85,000, depending on skills, experience, qualifications, and education.
• Full-time, permanent remote position.
• Opportunity to apply clinical expertise while improving healthcare access and outcomes.
• A supportive environment focused on professional growth and continuous learning.
• Potential opportunities for certification advancement and career development.
• Employee benefits package designed to support overall well-being.