Remote Utilization Management Nurse - Part-Time

Mass Digital Health; Southborough (MA); Remote; USD 39,000 - 55,000; Part time

Job summary

nirvanaHealth, under RxAdvance Corp., is seeking a part-time Utilization Management Nurse to support medical necessity reviews and care coordination remotely. The role involves prospective, concurrent, and retrospective UM activities with an emphasis on quality, cost efficiency, and regulatory compliance.

The ideal candidate holds an Associate's degree in nursing, RN licensure, 0–2 years in UM or case management, and knowledge of Medicare/Medicaid; bachelor's preferred.

Qualifications

• Associate degree in nursing is required.
• Background in utilization management or case management is preferred.
• Knowledge of Medicare, Medicaid, HMO, and private insurance is preferred.

Responsibilities

• Perform prospective, concurrent, and retrospective medical necessity reviews.
• Determine level of care and monitor length of stay based on severity of illness.
• Conduct initial clinical review in accordance with regulations.
• Ensure timely medical necessity reviews per guidelines.
• Coordinate discharge planning with RN case managers.
• Communicate criteria and rationale to members, providers, and facilities.

Skills

MS Word

MS Excel

MS Access

PowerPoint

RN license

Clinical judgement

Education

Associate's degree in Nursing

Bachelor’s degree preferred

Job description

nirvanaHealth, under RxAdvance Corp., is seeking a part-time Utilization Management Nurse to support medical necessity reviews and care coordination remotely. The role involves prospective, concurrent, and retrospective UM activities with an emphasis on quality, cost efficiency, and regulatory compliance.

The ideal candidate holds an Associate's degree in nursing, RN licensure, 0–2 years in UM or case management, and knowledge of Medicare/Medicaid; bachelor's preferred.