Job Description

Job Title: Utilization Management Nurse – Behavioral Health Focus (Remote)

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

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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