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Utilization Management Nurse – Behavioral Health Focus (Remote) ID-9047


Location Requirements:

Candidates must be located in one of the following preferred states: Arizona (AZ), Florida (FL), Georgia (GA), Idaho (ID), Iowa (IA), Kentucky (KY), Michigan (MI), Nebraska (NE), New Mexico (NM), New York (NY – outside greater NYC), Ohio (OH), Texas (TX), Utah (UT), Washington (WA – outside greater Seattle), or Wisconsin (WI).

Time Zone Preference

Eastern Time Zone is preferred, but not required.

Work Schedule

Tuesday through Saturday, 8:00 AM – 5:00 PM EST

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Compensation

$40 per hour

Position Type

Temporary to Permanent

Position Summary

A Managed Care Organization is seeking a Utilization Management Nurse to review provider-submitted service authorization requests and evaluate medical necessity, with a primary focus on behavioral health services. This position plays a key role in ensuring members receive appropriate and timely care by performing prior authorizations and concurrent reviews.

Day-to-Day Responsibilities
  • Review provider submissions for prior service authorizations, particularly in behavioral health
  • Evaluate requests for medical necessity and appropriate service levels
  • Provide concurrent review and prior authorization according to internal policies
  • Identify appropriate benefits and determine eligibility and expected length of stay
  • Collaborate with internal departments, including Behavioral Health and Long Term Care, to ensure continuity of care
  • Refer cases to medical directors as needed
  • Maintain productivity and quality standards
  • Participate in staff meetings and assist with onboarding of new team members
  • Foster professional relationships with internal teams and provider partners

Must-Have Requirements

  • Background in Behavioral Health services and/or experience with a Managed Care Organization (MCO) in Utilization Management

Licensure Requirements

  • Active, unrestricted RN, LPN, LCSW, or LPC license in any U.S. state

Required Education And Experience

  • Completion of an accredited Registered Nursing program (or equivalent combination of experience and education)
  • 2 years of clinical experience, preferably in hospital nursing, utilization management, or case management

Knowledge, Skills, And Abilities

  • Understanding of state and federal healthcare regulations
  • Experience with InterQual and NCQA standards
  • Strong organizational, communication, and problem-solving skills
  • Proficient in Microsoft Office and electronic documentation systems
  • Ability to work independently and manage multiple priorities
  • Professional demeanor and commitment to confidentiality and compliance with HIPAA standards
  • Team-oriented with the ability to build and maintain positive working relationships
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