Telephonic Utilization Management & Case Management Operations Registered Nurse | Remote

EXL Service; Denver (CO); Remote; USD 75,000 - 90,000; Full time

Job summary

Join a forward-thinking company as a Utilization Management Nurse, where you will play a crucial role in enhancing patient care through telephonic and digital outreach. In this remote position, you will review authorization requests, assess services for optimal outcomes, and collaborate with beneficiaries and providers to ensure effective care delivery. The role offers a dynamic work environment focused on improving healthcare outcomes and optimizing revenue. If you are passionate about patient care and have a strong nursing background, this opportunity is perfect for you.

Benefits

Bonuses

PTO

Region-specific perks

Qualifications

• Current RN license with multi-state privileges.
• 3+ years of clinical nursing experience required.

Responsibilities

• Review authorization requests for medical necessity.
• Develop and update individualized care plans.

Skills

Clinical Nursing Experience

Utilization Review

Case Management

MS Office Proficiency

Education

Bachelor's Degree in Nursing

Tools

MS Office

Teams

SharePoint

Job description

Telephonic Utilization Management & Case Management Operations Registered Nurse | Remote

Locations: Albuquerque, NM, USA; Atlanta, GA, USA; Austin, TX, USA; Bozeman, MT, USA; Cedar Rapids, IA, USA; Dallas, TX, USA; Denver, CO, USA; Fargo, ND, USA; Houston, TX, USA; Indianapolis, IN, USA; Kalispell, MT 59901, USA; Kansas City, KS, USA; Little Rock, AR, USA; Louisville, KY, USA; Memphis, TN, USA; Minneapolis, MN, USA; Missoula, MT, USA; Nashville, TN, USA; New Orleans, LA, USA; Oklahoma City, OK, USA; Omaha, NE, USA; Phoenix, AZ, USA; Pocatello, ID, USA; Salt Lake City, UT, USA; Sioux Falls, SD, USA; St. Louis, MO, USA; United States; Virtual

Company Overview: EXL (NASDAQ: EXLS) is a leading data analytics and digital operations company. We partner with clients using a data and AI-led approach to reinvent business models, drive better outcomes, and unlock growth. Founded in 1999, headquartered in New York, with over 55,000 employees worldwide. For more information, visit http://www.exlservice.com.

About EXL Health: We leverage human ingenuity, domain expertise, data, and analytics to improve healthcare outcomes, optimize revenue, and reduce waste. We work with payers, PBMs, provider organizations, and life sciences companies to transform care delivery, management, and payment systems.

Position: Utilization Management & Complex Case Manager, Registered Nurse | Remote

Are you passionate about patient care? Join us as a Utilization Management & Complex Case Management Nurse. You will review and approve authorization requests, provide case management for beneficiaries with complex conditions, and perform assessments and care planning via telephonic and digital outreach.

Our goal is to ensure beneficiaries receive appropriate, cost-effective care and support their health and functional capabilities.

Key Responsibilities:

• Review authorization requests for medical necessity and appropriateness.
• Assess services for optimal outcomes, cost-effectiveness, and compliance.
• Identify benefits and eligibility for treatments.
• Conduct authorization reviews and determine financial responsibility.
• Approve services or refer cases to stakeholders.
• Refer cases to Medical Directors and educate providers.
• Maintain clinical information in management systems.
• Make evidence-based decisions independently.
• Process requests within timelines and collaborate with teams.
• Develop and update individualized care plans with beneficiaries and providers.
• Coordinate activities to promote continuity of care.
• Monitor and evaluate care plans regularly.
• Collaborate with beneficiaries, providers, and community resources.

Work Schedule: Monday - Friday, 8-hour shifts aligned to state time zones (e.g., 9 am - 6 pm PT, 10 am - 7 pm MT, etc.)

Qualifications:

• Current, unrestricted RN license in residence with multi-state privileges or ability to obtain.
• At least 3 years of clinical nursing experience.
• 2+ years in utilization review for a health plan or inpatient facility.
• 1+ year as a case manager in a health plan or inpatient setting.
• Proficiency with MS Office, Teams, SharePoint, and multiple systems.
• U.S. Citizenship and ability to obtain Federal Security Clearance (DOD Security Clearance preferred).
• Private home office environment.

Preferred Qualifications:

• Bachelor’s degree in nursing.
• Experience with NCQA and URAC accreditation.
• Experience in hospital acute care, prior auth, utilization review, and knowledge of guidelines like InterQual or MCG.
• Health plan experience, especially with large carriers or federal programs.
• Active Certified Case Management (CCM) certification.
• Remote work experience.

EEO/Minorities/Females/Vets/Disabilities

For total rewards, visit https://www.exlservice.com/us-careers-and-benefits

Salary Range: $75,000 - $90,000, depending on location and experience. Other benefits include bonuses, PTO, and region-specific perks.