RN Utilization Manager — Remote Health Plan

copehealthcareconsulting; United States; On-site; USD 90,000 - 110,000; Full time

Benefits offered by this job

Wellness stipend

Paid parental leave

Job summary

COPE Health Solutions is seeking a Registered Nurse in Utilization Management to assess requests for medical services, authorize appropriate care, and ensure compliance with state and federal regulations. You will coordinate with physicians, care teams, and discharge planners to promote safe, cost-effective outcomes.

The role requires nursing licensure in preferred jurisdictions, experience with managed care or health plans, and proficiency in EMR systems.

Qualifications

• Compact Licensed RN; California and New York State preferred.
• Bachelor’s degree in nursing preferred; Associate degree in nursing is minimum requirement.
• Knowledge of Medicare and Medicaid regulations.
• Excellent organizational and time management skills, interpersonal skills, verbal and written communication skills.
• Working knowledge of Microsoft Excel, PowerPoint, and Word; strong typing skills.

Responsibilities

• Conducts comprehensive review of all components related to service requests, including interviews with members and staff.
• Performs prior authorization and concurrent reviews to ensure medical necessity and appropriate setting.
• Ensures compliance with state and federal regulatory standards and policies.
• Participates in case conferences with management.
• Identifies opportunities for alternative care options and safe discharge planning.
• Reviews services for plan benefits and regulatory requirements to ensure proper authorization.

Skills

Organizational skills

Time management

Communication skills

Interpersonal skills

MS Excel

PowerPoint

Word

Typing skills

EMR proficiency

Education

Associate degree in nursing

Bachelor’s degree in nursing preferred

Tools

EMR systems

Milliman criteria (MCG)

Job description

COPE Health Solutions is seeking a Registered Nurse in Utilization Management to assess requests for medical services, authorize appropriate care, and ensure compliance with state and federal regulations. You will coordinate with physicians, care teams, and discharge planners to promote safe, cost-effective outcomes.

The role requires nursing licensure in preferred jurisdictions, experience with managed care or health plans, and proficiency in EMR systems.