Remote Nurse Utilization Manager

COPE Health Solutions; United States; Remote; USD 90,000 - 110,000; Full time

Benefits offered by this job

Comprehensive insurance plans

Wellness stipend

Paid parental leave

Job summary

COPE Health Solutions is seeking a qualified Utilization Management Nurse (RN) to assess member needs, determine medical necessity and coordinate care across providers and care teams. This full-time, remote position reports to Medical Management and focuses on timely, cost-effective decision-making.

Responsibilities include prior authorizations, case conferences, documentation in EMR, and ensuring compliance with Medicare/Medicaid rules while supporting safe discharge and transition back to the

Qualifications

• Compact Licensed RN, California and New York State preferred.
• Bachelor’s degree in nursing preferred; Associate degree in nursing is minimum requirement.
• Knowledge of Medicare and Medicaid regulations.
• Excellent organizational and time management skills, interpersonal skills, verbal and written communication skills.
• Working knowledge of Microsoft Excel, Power-Point, and Word and strong typing skills.
• Knowledge of Medicaid and/or Medicare regulations.
• Knowledge of Milliman criteria (MCG).
• For UM Only: Experience must be with a Managed Care Organization or Health Plan.
• Experience working with community-based organizations in underserved communities.

Responsibilities

• Conducts comprehensive review of all components related to requests for services which includes a clinical record review and interviews with members, clinical staff, medical providers, paraprofessional staff, caregivers and other relevant sources as necessary.
• Performs prior authorization and concurrent reviews to ensure extended treatment is medically necessary and being conducted in the right setting.
• Reviews requests for outpatient and inpatient admission; approves services or consults with medical directors when case does not meet medical necessity criteria.
• Ensures compliance with state and federal regulatory standards and VNS Health policies and procedures.
• Participates in case conferences with management.
• Maintains accurate record of all care management. Maintains written progress notes and verbal communications according to program guidelines.
• Provides input and recommendations for design and development of, processes and procedures for effective member case management, efficient department operations, and excellent customer service.
• Keeps current with all health plan changes and updates through on-going training, coaching and educational materials.

Skills

Strong communication

Interpersonal skills

Time management

Microsoft Excel

PowerPoint

Word

EMR systems proficiency

Outlook

Data entry

Education

Bachelor's degree in nursing (BSN preferred; ADN minimum)

RN license in CA and NY preferred

Tools

EMR systems

Outlook

Job description

COPE Health Solutions is seeking a qualified Utilization Management Nurse (RN) to assess member needs, determine medical necessity and coordinate care across providers and care teams. This full-time, remote position reports to Medical Management and focuses on timely, cost-effective decision-making.

Responsibilities include prior authorizations, case conferences, documentation in EMR, and ensuring compliance with Medicare/Medicaid rules while supporting safe discharge and transition back to the