About the Role:

• We are looking for a Utilization Management Nurse to join our team.
• This position will primarily focus on inpatient medical necessity/utilization review and other utilization management activities to ensure client Healthcare members receive the right care at the right time.
• This role will involve reviewing and evaluating members requiring hospitalization and/or procedures, providing prior authorizations, and assessing services to ensure optimal outcomes and compliance with regulations.

Responsibilities: -

• Provide concurrent review and prior authorizations for Client members as part of the Utilization Management team
• Identify appropriate benefits, eligibility, and expected length of stay for members seeking treatments and procedures
• Collaborate with other departments to enhance continuity of care for members
• Maintain department productivity and quality measures
• Attend staff meetings and mentor new team members
• Complete work plan objectives and projects in a timely manner
• Build and maintain professional relationships with providers and customers
• Consult with medical directors and ensure compliance with safety standards

Education Qualification: -

Either a VA or compact RN license

Required Skills: -

• Preferably LTSS experience, knowledge of VA Medicaid a plus
• Ability to communicate effectively and work well with others
• Strong organizational skills and ability to manage multiple priorities
• Knowledge of state and federal regulations 
• Familiarity with Interqual and other references for length of stay and medical necessity determinations
• Experience with NCQA
• Computer literate with proficiency in MS Office Products This position is 100% remote and requires candidates from specific states. The desired work hours are M-F 8:00-4:30 or 8:00-5:00 EST.
• Additional equipment needed includes an extra monitor.
• If you meet the requirements and are looking to make a difference in healthcare, we encourage you to apply for this role.