Remote Utilization Management RN - Care Quality & UM Leader

Renown Health; Reno (NV); Remote; USD 90,000 - 115,000; Full time

Job summary

Renown Health is seeking a Utilization Management RN to apply medical necessity criteria for prospective and concurrent reviews. You will work with an interdisciplinary team to ensure medically necessary, cost-effective care at the appropriate level of care.

The role includes tracking denials, supporting discharge planning, and ensuring timely disposition of cases. Knowledge of CMS/NCQA standards is essential.

Qualifications

• RN degree and licensure in Nevada or applicable state
• 2+ years clinical experience in inpatient/outpatient settings
• Managed care utilization management experience preferred
• Utilization Management Certification desirable
• Proficient with MS Office and online learning platforms

Responsibilities

• Apply medical necessity guidelines for prospective and concurrent reviews
• Coordinate with interdisciplinary team to ensure appropriate level of care
• Document medical necessity determinations and communications in the review system
• Identify avoidable days and denials; report metrics to leadership
• Refer referrals to Medical Director or external review as policy dictates
• Support discharge planning and care transitions to maintain continuity of care

Skills

Interpersonal communication

Critical thinking

Regulatory knowledge

Timely problem solving

Documentation accuracy

Regulatory compliance (CMS/NCQA)

Adaptability to remote work

Education

Bachelor of Science in Nursing (BSN) preferred

Tools

Microsoft Office Suite

Job description

Renown Health is seeking a Utilization Management RN to apply medical necessity criteria for prospective and concurrent reviews. You will work with an interdisciplinary team to ensure medically necessary, cost-effective care at the appropriate level of care.

The role includes tracking denials, supporting discharge planning, and ensuring timely disposition of cases. Knowledge of CMS/NCQA standards is essential.