Utilization Review Nurse - Remote

The Utilization Review Nurse at Martin's Point Health Care is responsible for reviewing medical necessity for inpatient and outpatient services, coordinating care transitions, and ensuring high-quality, cost-efficient outcomes within a healthcare organization that values trust, respect, and continuous learning.

Location: Remote (US)

Responsibilities

• Review prior authorization requests for medical necessity, including prior authorization, concurrent review, and retrospective review.
• Utilize evidence-based criteria, governmental policies, and internal guidelines for medical necessity reviews.
• Manage review of medical claims disputes, records, and authorizations for billing, coding, and compliance.
• Collaborate with healthcare providers, internal departments, and members to promote resource utilization and coordinate care.
• Coordinate referrals to Care Management as appropriate.
• Ensure healthcare management within benefits structures and compliance with regulations such as DOD, Medicaid, Medicare, NCQA, and state insurance laws.
• Document reviews and decisions accurately and timely.
• Participate as a member of an interdisciplinary team in the Health Management Department.
• Maintain a caseload for concurrent cases and assist in team coverage.
• Build and maintain relationships with community providers.
• Act as a liaison to ensure appropriate care levels and timing.
• Mentor new staff members.
• Meet or exceed quality and productivity standards.
• Contribute to policy updates and quality initiatives.
• Analyze population data to inform program development.
• Demonstrate flexibility in a fast-paced environment and handle multiple case types.
• Perform extra duties as needed, including weekend rotations.

Requirements

• 3+ years of clinical nursing experience as an RN, preferably in a hospital setting.
• 2+ years of utilization management experience in a health plan UM department.