Utilization Management Nurse

We are seeking a dedicated Utilization Management Nurse to provide timely and appropriate prior approval services to members and healthcare providers. The role involves making clinical determinations based on medical policies and criteria, completing post-service reviews, and supporting members throughout their healthcare journey.

Responsibilities

• Provide timely prior approval for services, procedures, and out-of-network referrals by obtaining necessary medical information.
• Conduct post-service reviews for medical necessity and experimental/investigational services.
• Offer precertification and continued stay reviews to members in various healthcare settings.
• Assist in developing and facilitating discharge plans and refer cases to Case Management as needed.
• Collaborate with healthcare provider staff to gather medical information and facilitate discharge planning.
• Process utilization management requests by interpreting medical policy, criteria, and benefit information.
• Engage with Medical Directors and Physician Reviewers for services not meeting medical criteria.
• Document review processes and decisions accurately and consistently within the review documentation system.
• Communicate approval and denial decisions to members and providers according to regulatory standards.
• Meet quality assurance and production metrics established for the utilization management unit.

Requirements

• Registered Nurse (RN) or Licensed Practical Nurse (LPN) with active and unrestricted license in Iowa or South Dakota.
• 4+ years of diverse clinical experience, including critical care, acute care, and outpatient settings.
• Experience in utilization management, utilization review, and case management.
• Strong verbal and written communication skills.
• Ability to apply analytical and critical thinking skills to make independent decisions.
• Proficient in diagnosis and procedure coding systems (e.g., ICD-10, HCPCS, CPT).

Qualifications

• Completion of an accredited nursing program.
• Acute Care, Home Health, and Medical Surgery experience preferred.
• Strong technical acumen and ability to learn new systems quickly, including Microsoft Office and clinical documentation platforms.
• Demonstrated commitment to service excellence and patient/member advocacy.

Work Environment

This 100% remote role involves working primarily on prior approval reviews. The work hours are from 8 AM to 5 PM CST, with a contract length of 6-8 months and a possibility for extension. A compact license is required for individuals residing outside of Iowa or South Dakota. The role includes a 2-3 week training period with a buddy system for support.

Pay

The pay range for this position is $40.00/hr. Individual compensation offered within this range will depend on qualifications, skills, relevant experience, job knowledge, geographic location, internal equity, and other pertinent job-related factors.

Benefits

If eligible, the benefits available for this temporary role may include:

• Medical, dental, and vision
• Critical Illness, Accident, and Hospital insurance
• 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available
• Life Insurance (Voluntary Life & AD&D for the employee and dependents)
• Short and long-term disability
• Health Spending Account (HSA)
• Transportation benefits
• Employee Assistance Program
• Time Off/Leave (PTO, Vacation or Sick Leave)