Remote Utilization Review Nurse — Elevate Patient Care

American Health Partners; Franklin (TN); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Affordable medical/dental/vision plans

Paid time-off and holidays for full‑t​

TeleDoc 24/7/365 access to doctors

Disability plans (short- and long-term

Employee Assistance Plan (EAP)

401K retirement with company match

Employee Referral Bonus Program

Job summary

American Health Plans, a division of American Health Partners Inc., invites applications for a Utilization Review Nurse in Franklin, TN. You will support the Clinical Services Department and Medical Director to ensure medically necessary, compliant care.

Responsibilities include reviews across pre-service, concurrent, and retrospective UM, collaboration with providers, and adherence to regulatory timeframes. Strong clinical judgment and communication are essential.

Qualifications

• At least 1 year experience in utilization management with a health plan or hospital UM.
• Current RN license; CCM credential is a plus.
• Knowledge of InterQual or MCG and Medicare regulations.
• Excellent customer service and communication skills.
• Ability to work independently and as part of a team, under pressure.

Responsibilities

• Assess medical necessity and quality of care for plan members.
• Identify placement settings with appropriate autonomy.
• Gather clinical data from providers and apply review criteria.
• Certify cases meeting criteria and consult with physicians.
• Maintain regulatory timeframes and alert leadership to risks.

Skills

RN license

Utilization management

InterQual/MCG knowledge

Clinical documentation

Customer service

Education

Registered Nurse license

Certified Case Manager credential (CCM)

Job description

American Health Plans, a division of American Health Partners Inc., invites applications for a Utilization Review Nurse in Franklin, TN. You will support the Clinical Services Department and Medical Director to ensure medically necessary, compliant care.

Responsibilities include reviews across pre-service, concurrent, and retrospective UM, collaboration with providers, and adherence to regulatory timeframes. Strong clinical judgment and communication are essential.