Utilization Management Nurse – Behavioral Health Focus (Remote)

<strong>Job Title:</strong> Utilization Management Nurse – Behavioral Health Focus (Remote)<br><br><strong>Location Requirements:<br><br></strong>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).<br><br><strong>Time Zone Preference<br><br></strong>Eastern Time Zone is preferred, but not required.<br><br><strong>Work Schedule<br><br></strong>Tuesday through Saturday, 8:00 AM – 5:00 PM EST<br><br><strong>Compensation<br><br></strong>$40 per hour<br><br><strong>Position Type<br><br></strong>Temporary to Permanent<br><br><strong>Position Summary<br><br></strong>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.<br><br><strong>Day-to-Day Responsibilities<br><br></strong><ul><li>Review provider submissions for prior service authorizations, particularly in behavioral health </li><li>Evaluate requests for medical necessity and appropriate service levels </li><li>Provide concurrent review and prior authorization according to internal policies </li><li>Identify appropriate benefits and determine eligibility and expected length of stay </li><li>Collaborate with internal departments, including Behavioral Health and Long Term Care, to ensure continuity of care </li><li>Refer cases to medical directors as needed </li><li>Maintain productivity and quality standards </li><li>Participate in staff meetings and assist with onboarding of new team members </li><li>Foster professional relationships with internal teams and provider partners <br><br></li></ul><strong>Must-Have Requirements<br><br></strong><ul><li>Background in Behavioral Health services and/or experience with a Managed Care Organization (MCO) in Utilization Management <br><br></li></ul><strong>Licensure Requirements<br><br></strong><ul><li>Active, unrestricted RN, LPN, LCSW, or LPC license in any U.S. state <br><br></li></ul><strong>Required Education And Experience<br><br></strong><ul><li>Completion of an accredited Registered Nursing program (or equivalent combination of experience and education) </li><li>2 years of clinical experience, preferably in hospital nursing, utilization management, or case management <br><br></li></ul><strong>Knowledge, Skills, And Abilities<br><br></strong><ul><li>Understanding of state and federal healthcare regulations </li><li>Experience with InterQual and NCQA standards </li><li>Strong organizational, communication, and problem-solving skills </li><li>Proficient in Microsoft Office and electronic documentation systems </li><li>Ability to work independently and manage multiple priorities </li><li>Professional demeanor and commitment to confidentiality and compliance with HIPAA standards </li><li>Team-oriented with the ability to build and maintain positive working relationships</li></ul>

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