Remote USRN Utilization Manager (Associate III)

F-Prime Capital; United States; Remote; USD 75,000 - 105,000; Full time

Job summary

HealthEdge is seeking a USRN Utilization Management professional to join the USRN - Utilization Management team. This role involves reviewing medical necessity, length of stay, and level of care across inpatient and outpatient settings.

The ideal candidate is a registered nurse with current US license, with 3+ years of clinical nursing experience and 2+ years in utilization or case management, plus familiarity with NCQA standards and HealthEdge platform.

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 is a plus.
• HealthEdge HRCM or Guiding Care experience is a plus.

Responsibilities

• Perform prospective, concurrent, and retrospective reviews to ensure medical necessity, appropriate length of stay, the intensity of service, and level of care, including appeals.
• Review, research, and prepare documentation related to retrospective review requests and appeals per NCQA standards.
• Coordinate with appropriate medical and support personnel to identify and recommend alternative treatment plans.
• Follow out-of-area/out-of-network services and advise on patient transfer or alternative plans of care.
• Coordinate care through the health care continuum including member outreach assessments and discharge planning needs.

Skills

Clinical nursing experience

Care coordination

Medical necessity assessment

Patient education

Education

RN License

Job description

HealthEdge is seeking a USRN Utilization Management professional to join the USRN - Utilization Management team. This role involves reviewing medical necessity, length of stay, and level of care across inpatient and outpatient settings.

The ideal candidate is a registered nurse with current US license, with 3+ years of clinical nursing experience and 2+ years in utilization or case management, plus familiarity with NCQA standards and HealthEdge platform.