Schedule: Monday – Friday | 8:00 AM – 5:00 PM
Work Model: 100% Remote (Onsite visit required for equipment pickup)
Employment Type: Contract
The Utilization Review Nurse is responsible for monitoring and providing clinical oversight to ensure compliance with contractual, regulatory, and statutory requirements related to members’ physical/acute care and behavioral health services. This role supports appropriate utilization of healthcare services and serves as a clinical resource to internal and external stakeholders.
Key ResponsibilitiesMonitor overutilization and underutilization of healthcare services
Conduct utilization reviews, case file reviews, and audits
Provide technical assistance and clinical oversight to ensure compliance with applicable regulations and guidelines
Gather, analyze, organize, and evaluate information from multiple sources, including utilization data and medical records
Coordinate care with internal teams and external providers as needed
Make referrals for medically necessary covered services
Participate in clinical staffing and interdisciplinary reviews as required
Serve as a clinical resource for utilization management and covered service determinations
Bachelor of Science in Nursing (BSN)
Minimum 2 years of experience working as a Registered Nurse
Minimum 1 year of experience in behavioral health
Active Registered Nurse (RN) license in the applicable state
FPCC certification
No weekends required
Fully remote role with limited onsite requirement for equipment setup
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