Remote RN - Utilization Management Specialist

The Blue Venture Fund; United States; Remote; USD 85,000 - 115,000; Full time

Job summary

HealthEdge is seeking a USRN Utilization Management Associate III to perform prospective, concurrent, and retrospective reviews across inpatient and outpatient services, ensuring medical necessity and appropriate care. The role requires a current US RN license and 3+ years of direct clinical nursing experience.

Experience with HRCM or Guiding Care is a plus, with additional regulatory/accreditation knowledge.

Qualifications

• Registered Nurse with current, unrestricted US RN license.
• 3+ years of direct, clinical nursing experience.
• 2+ years in US healthcare in utilization management or case management.
• MCG Certification will be a plus.
• HealthEdge HRCM or Guiding Care experience is a plus.

Responsibilities

• Perform prospective, concurrent, and retrospective reviews of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, the intensity of service, and level of care.
• Review, research, and prepare documentation related to retrospective review requests and appeals per regulatory/accreditation standards.
• Coordinate with medical and support personnel to identify and recommend care levels, services, or plans of care.
• Follow out-of-area/out-of-network services and recommend transfers to in-network services or alternative plans of care.
• Establish care plans and coordinate care through the health care continuum including member outreach assessments.
• Coordinate discharge planning needs with internal and external entities.
• Review patterns of care related to disease progression and coordinate services.
• Resolve benefits, member eligibility, and care coordination issues as needed.
• Develop and deliver provider education on policies and benefits.

Skills

Nursing experience

Clinical assessment

Communication skills

Education

RN license

Tools

HRCM

Guiding Care

Job description

HealthEdge is seeking a USRN Utilization Management Associate III to perform prospective, concurrent, and retrospective reviews across inpatient and outpatient services, ensuring medical necessity and appropriate care. The role requires a current US RN license and 3+ years of direct clinical nursing experience.

Experience with HRCM or Guiding Care is a plus, with additional regulatory/accreditation knowledge.