About the job
Utilization Management Nurse (RN/LPN) – Managed Care / Appeals & Authorization (Remote)
Overview
We are seeking an experienced and detail-oriented Utilization Management Nurse to support clinical review operations within a fast-paced managed care environment. This role is responsible for conducting medical necessity reviews, processing appeals, coordinating with providers and external review agencies, and ensuring compliance with CMS and state regulatory requirements. The ideal candidate will bring strong clinical judgment, utilization management expertise, and the ability to navigate complex cases while maintaining exceptional documentation standards.
Key Responsibilities
Utilization Management Operations
- Perform inpatient admission certification, concurrent review, and outpatient/ancillary authorization reviews.
- Evaluate medical necessity, level of care (LOC), and length of stay (LOS) using InterQual, CMS/Medicare guidelines, and internal medical policies.
- Ensure all reviews and determinations are completed within required turnaround times (TATs).
Appeals & Clinical Review
- Review clinical appeals and summarize findings for Physician Advisor or Medical Director review.
- Coordinate external appeal processes with External Review Agencies (ERA) and Clinical Peer Reviewers.
- Ensure timely submission of external review documentation and accurate implementation of final determinations.
Documentation & Compliance
- Maintain accurate and audit-ready documentation within UM and Appeals platforms.
- Document clinical findings, decision rationales, and review outcomes in accordance with regulatory and accreditation standards.
- Support compliance with CMS, NCQA, URAC, and state-mandated guidelines.
Provider & Member Collaboration
- Partner with PCPs and providers to obtain clinical information necessary for case review.
- Communicate authorization and appeal determinations to providers and members.
- Educate stakeholders on appropriate treatment alternatives and next steps when applicable.
Reporting & Trend Analysis
- Analyze pharmacy claims, encounter data, and health risk assessments to identify utilization trends and member needs.
- Escalate complex or high-risk cases appropriately to Physician Advisors or Medical Directors.
Qualifications
Required
- Active, unrestricted RN or LPN license.
- Minimum 3 years of experience in Utilization Management, Clinical Appeals, Care Coordination, or Discharge Planning.
- Strong knowledge of CMS Medicaid/Medicare regulations and appeal timelines.
- Experience using InterQual or MCG criteria for medical necessity and level-of-care determinations.
- Proficiency with UM and clinical documentation platforms such as HealthEdge, Jiva, or Salesforce Health Cloud.
- Ability to exercise sound clinical judgment and escalate cases appropriately.
Preferred
- Certified Case Manager (CCM) or ABQAURP certification.
- Experience with Medicare Advantage, MLTC, SNP, or other managed care lines of business.
- Prior experience handling external appeals or regulatory audits involving CMS or DOH.
- Clinical expertise in Behavioral Health, Oncology, or Complex Surgical Services.
- Experience conducting internal UM quality audits for NCQA or URAC compliance.
- Bilingual proficiency strongly preferred.
Ideal Candidate
The ideal candidate is highly organized, analytical, and comfortable working in a deadline-driven managed care environment. They possess strong communication skills, exceptional attention to detail, and the ability to collaborate effectively with interdisciplinary teams, providers, and regulatory partners.