Remote Utilization Review Nurse - RN (Medicare/UM)

American Health Communities; Franklin (TN); Remote; USD 80,000 - 105,000; Full time

Benefits offered by this job

Affordable Medical/Dental/Vision

Generous paid time-off

TeleDoc 24/7/365 access to doctors

Disability plans

Employee Assistance Plan (EAP)

401K with company match

Employee Referral Bonus Program

Job summary

American Health Plans in Franklin, TN is seeking a Utilization Review Nurse to assess medical necessity and quality of care across pre-service, concurrent, and retrospective reviews. You will support the Clinical Services Department and Medical Director to ensure compliant access to necessary services.

This role requires an RN license, experience in utilization management, knowledge of InterQual/MCG criteria, and strong communication skills.

Qualifications

• At least 1 year of experience in utilization management with a health plan or hospital-based UR department using InterQual or MCG.
• Clinical knowledge of Medicare regulations and URAC/NCQA principles.
• RN license, CCM credential a plus.

Responsibilities

• Assess medical necessity, quality of care, level of care, and appropriateness of health care services for plan members.
• Identify placement settings offering appropriate autonomy based on medical necessity.
• Gather clinical data from requesting providers including specialists and facilities.
• Apply review criteria to determine medical necessity using provided data.
• Certify cases meeting criteria and consult when reviews are unclear.
• Refer cases to case management or medical consultation as indicated.
• Adhere to accreditation, contractual, and regulatory timeframes.
• Flag potential risk management issues to the Director or designee.
• Execute other duties as assigned.

Skills

Utilization management

Medicare regulations

Interqual/MCG

RN license

Certified Case Manager (CCM)

Communication skills

Education

Associates or better in Nursing

Job description

American Health Plans in Franklin, TN is seeking a Utilization Review Nurse to assess medical necessity and quality of care across pre-service, concurrent, and retrospective reviews. You will support the Clinical Services Department and Medical Director to ensure compliant access to necessary services.

This role requires an RN license, experience in utilization management, knowledge of InterQual/MCG criteria, and strong communication skills.