Remote Utilization Management Nurse

Santa Barbara Cottage Hospital; United States; Remote; USD 65,000 - 90,000; Full time

Job summary

Santa Barbara Cottage Hospital is seeking a licensed practical nurse to join BHPS Utilization Management as a remote reviewer of medical necessity and benefit determinations. You will assess cases using clinical guidelines and coordinate with providers and departments to support timely, compliant decisions.

The role requires reviewing both inpatient and outpatient services, familiarity with URAC and NCQA guidelines, and the ability to work independently in a fast-paced managed care environment.

Qualifications

• Current LPN license with active, unrestricted status.
• Proficient in Microsoft Office applications.
• Ability to work independently in a remote setting.
• Strong organizational and time-management skills.
• Experience with Utilization Review processes and guidelines.
• Knowledge of MCG and CMS criteria.
• 2+ years in a UM team within managed care.
• 3+ years in clinical nursing preferred.

Responsibilities

• Performs clinical utilization reviews using evidence-based guidelines and policies.
• Identifies potential Third-Party Liability and Coordination of Benefit cases.
• Collaborates with healthcare partners to ensure timely review of services.
• Provides referrals to Case Management and Quality Departments as needed.
• Develops and reviews member-centered documentation reflecting determinations.
• Identifies quality-of-care issues and intervenes as appropriate.
• Triages and prioritizes cases to meet turnaround times.
• Prepares and presents cases to Medical Director for determinations.
• Communicates determinations to providers and members per regulatory requirements.
• Duties as assigned.

Skills

LPN license

Microsoft Office

Independent work

Time management

Adaptability

URAC familiarity

NCQA familiarity

Job description

Santa Barbara Cottage Hospital is seeking a licensed practical nurse to join BHPS Utilization Management as a remote reviewer of medical necessity and benefit determinations. You will assess cases using clinical guidelines and coordinate with providers and departments to support timely, compliant decisions.

The role requires reviewing both inpatient and outpatient services, familiarity with URAC and NCQA guidelines, and the ability to work independently in a fast-paced managed care environment.