Utilization Management Nurse – Behavioral Health Focus (Remote)

Remote, USA Full-time Posted 2025-05-22

Job Title: Utilization Management Nurse – Behavioral Health Focus (Remote) Location Requirements: 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). Time Zone Preference Eastern Time Zone is preferred, but not required. Work Schedule Tuesday through Saturday, 8:00 AM – 5:00 PM EST Compensation $40 per hour Position Type Temporary to Permanent Position Summary 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. Day-to-Day Responsibilities <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 </li></ul>Must-Have Requirements <ul><li>Background in Behavioral Health services and/or experience with a Managed Care Organization (MCO) in Utilization Management </li></ul>Licensure Requirements <ul><li>Active, unrestricted RN, LPN, LCSW, or LPC license in any U.S. state </li></ul>Required Education And Experience <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 </li></ul>Knowledge, Skills, And Abilities <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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