Remote Utilization Management Nurse (Part-Time)

Rxadvance Corporation

Southborough (MA)

Remote

USD 34,000 - 55,000

Part time

14 days+

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Job summary

nirvanaHealth, operating under RxAdvance Corp., is seeking a Utilization Management Nurse for a part-time remote role. The position focuses on prospective, concurrent, and retrospective medical necessity reviews and care coordination to ensure quality, cost-effective healthcare services in compliance with standards.

The role requires an active RN license and 0–2 years of UM or case management experience, with Medicare/Medicaid knowledge being a plus.

Qualifications

Associate’s degree in nursing required.
Bachelor’s degree in nursing preferred.
Active RN license required.
0–2 years in utilization management or case management preferred.
Knowledge of Medicare/Medicaid, HMO and private insurance preferred.

Responsibilities

Performs prospective, concurrent, and retrospective medical necessity reviews for healthcare products and services using clinical criteria or evidence-based guidelines.
Performs level of care determinations and monitors length of stay based on illness severity and service intensity.
Conducts initial clinical review per accreditation, laws, and regulations.
Ensures timeliness of medical necessity reviews per guidelines.
Verifies accuracy of codes and services with proper documentation.
Coordinates discharge planning and transition of care with RN case managers and healthcare team.