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
...surface fleet area in the U.S. Since it opened in 1942, it has become a key hub with a harbor for 34 ships and a runway for most Department of Defense aircraft. The Marine Corps Support Facility Blount Island (MCSF-BI) covers 911 acres on the eastern side of Blount Island...
...healthcare company committed to expanding access to virtual care, pharmacy services, and diagnostics by making them more affordable and... ...care. About the role: We are looking for a Customer Service Representative to serve as the face of our Virtual Patient Care...
...Goodcents is now hiring on Noland Road! We're looking to hire Crew Members at our Goodcents location 3801 S Noland Rd Ste Iin Independence, MO.Discounted employeemeals, competitive wages, and even better, no late nights to cut into your social life! This opportunity...
...Part-Time Cleaner Job Summary The Cleaner performs cleaning and general upkeep of an assigned area. Job Duties Cleaners are... ...stand, walk, bend, and lift up to 25 lbs for the duration of the shift. Must be able to successfully pass a background check and...
...Job Title: Behavioral Health Utilization Review (UR) Nurse Location: Phoenix, AZ Job Type: Contract Schedule: MondayFriday... ...Rate: $32$34 per hour Work Arrangement: 100% Remote (initial onsite visit required to receive equipment) Position...