Utilization Management Nurse Consultant - Clinical Precertification RN (Medicare)
Remote | Full-Time | Monday-Friday
Are you a Registered Nurse looking to leverage your clinical expertise in a non-bedside role? Join our Utilization Management team and help ensure members receive the right care, at the right time, in the right setting.
What You'll Do
- Review clinical cases and make coverage determinations using evidence-based criteria
- Collaborate with providers and interdisciplinary care teams to support treatment planning
- Apply clinical judgment to utilization management and prior authorization decisions
- Identify opportunities to improve quality, outcomes, and member experience
- Serve as a trusted clinical resource for internal and external stakeholders
Required Qualifications
- Active, unrestricted RN license in the state of residence
- Minimum 3 years of RN experience, including at least 1 year in Medical-Surgical Nursing
- Strong clinical assessment, critical thinking, and decision-making skills
- Proficiency with Microsoft Office applications, including Outlook, Teams, and Excel
- Associate Degree in Nursing (ADN)
- Ability to work Monday-Friday, 9:00 AM-5:30 PM in your local time zone
Note: Utilization Management is a 24/7 operation. Schedules may include occasional evenings, weekends, and holidays based on business needs.
Preferred Qualifications
- Utilization Management, Prior Authorization, or Care Management experience
- Managed care experience
- Experience using MedCompass or similar UM platforms
- Ambulatory surgery or outpatient clinical experience
- Bachelor of Science in Nursing (BSN)
Work-from-Home Requirements
- Direct wired internet connection (minimum 25 Mbps download / 3 Mbps upload); Wi-Fi and satellite internet are not permitted
- Dedicated, private workspace that complies with HIPAA and company security requirements
- Ability to work from your confirmed state and city of residence
- Company-provided equipment includes computer, monitor(s), keyboard, and headset
- Employees are responsible for providing appropriate workspace furniture
- Commitment to maintaining required internet speeds and remote work standards
Technical Requirements
- Ability to navigate multiple monitors and applications simultaneously
- Comfortable using Teams, Outlook, email, calendars, and virtual meeting platforms
- Experience with Microsoft 365 applications (Teams, Outlook, Word, Excel, PowerPoint) or similar tools
- Ability to securely access systems, including VPNs and healthcare applications
- Basic troubleshooting skills, including resolving connectivity and application issues
- Willingness to learn new technology and adapt to evolving business needs
Anticipated Weekly Hours: 40
Time Type: Full time
Pay Range: The typical pay range for this role is: $29.10 - $62.32