Remote Utilization Review Nurse — Medicare Care Quality

American Health Plans; Franklin (TN); Remote; USD 60,000 - 85,000; Full time

Benefits offered by this job

Affordable Medical/Dental/Vision

Generous PTO and holidays

TeleDoc 24/7 access

Disability plans

Employee Assistance Plan

401K with company match

Employee Referral Bonus Program

Job summary

American Health Plans, a division of American Health Partners Inc., is hiring a Utilization Review Nurse in Franklin, TN. You will assess medical necessity and quality of care through pre-service, concurrent, and retrospective reviews to support regulatory compliance and patient outcomes.

The role requires an active RN license, an Associates or higher in Nursing, and 1 year in utilization management. CCM is a plus; strong communication and teamwork are essential for success.

Qualifications

• RN license required.
• Associates or bachelor’s degree in Nursing or higher.
• 1 year experience in utilization management with health plan or hospital UM.
• Broad knowledge of Medicare regulations and guidance.
• CCM credential is a plus.

Responsibilities

• Assess medical necessity, quality of care, level of care for plan members.
• Identify placement settings offering appropriate autonomy based on medical necessity.
• Gather clinical data from providers to support reviews.
• Apply review criteria and certify cases meeting criteria.
• Consult with physicians when reviews don’t meet criteria.
• Coordinate with internal teams for risk management and escalations.

Skills

Strong communication

Critical thinking

Independent work

Team collaboration

Privacy/compliance

InterQual

MCG

Education

Associate's degree in Nursing

Tools

InterQual

MCG

Job description

American Health Plans, a division of American Health Partners Inc., is hiring a Utilization Review Nurse in Franklin, TN. You will assess medical necessity and quality of care through pre-service, concurrent, and retrospective reviews to support regulatory compliance and patient outcomes.

The role requires an active RN license, an Associates or higher in Nursing, and 1 year in utilization management. CCM is a plus; strong communication and teamwork are essential for success.