Telephonic Utilization Management & Case Management Operations Registered Nurse | Remote

EXL Service; Missoula (MT); Remote; USD 75,000 - 90,000; Full time

Job summary

Join a forward-thinking organization as a Utilization Management & Complex Case Management Nurse. This remote position offers the chance to make a significant impact on patient care by reviewing authorization requests and providing case management for beneficiaries with complex conditions. You'll work with a dynamic team to ensure quality, cost-effective care while leveraging your clinical expertise. If you are passionate about improving health outcomes and enjoy collaborating with multidisciplinary teams, this opportunity is tailored for you. Embrace a role that not only challenges you but also allows you to contribute to meaningful healthcare solutions.

Benefits

Bonuses

PTO

Region-specific perks

Qualifications

• Active RN license with multi-state privileges.
• 3+ years clinical nursing experience, 2+ years in utilization review.

Responsibilities

• Review authorization requests using clinical judgment.
• Conduct comprehensive assessments and develop care plans.

Skills

Clinical Judgment

Utilization Review

Case Management

MS Office

Communication Skills

Education

Bachelor’s Degree in Nursing

Tools

MS Teams

SharePoint

Job description

Telephonic Utilization Management & Case Management Operations Registered Nurse | Remote

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

Company Overview and Culture

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 with speed. Headquartered in New York with over 55,000 employees worldwide, we serve industries including insurance, healthcare, banking, media, and retail. Visit http://www.exlservice.com for more information.

About EXL Health

We leverage human ingenuity and domain expertise to improve outcomes, optimize revenue, and maximize profitability across the healthcare ecosystem. Our solutions focus on transforming care delivery, management, and payment processes, working with data on over 260 million lives.

We assist payers in improving member care, managing population risk, and reducing administrative waste; Pharmacy Benefit Managers in managing drug benefits and reducing costs; provider organizations in managing risk and outcomes; and Life Sciences companies with data insights and analytics.

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 to review and approve authorization requests, provide case management for beneficiaries with complex conditions, and ensure quality, cost-effective care via telephonic and digital outreach.

Our goal is to help beneficiaries regain or improve their health and functional capabilities, support self-care, and facilitate access to healthcare and community resources.

Key Responsibilities

• Review authorization requests for medical necessity and appropriate care using clinical judgment and evidence-based criteria.
• Assess services to ensure optimal outcomes, cost-effectiveness, and regulatory compliance.
• Identify benefits and eligibility for treatments and procedures.
• Conduct authorization reviews and determine financial responsibility.
• Approve services or escalate cases to stakeholders.
• Refer cases to clinical programs and collaborate with Medical Directors.
• Educate providers on utilization and management processes.
• Maintain clinical information in medical management systems.
• Make independent, evidence-based decisions, even in ambiguous situations.
• Analyze clinical requests against guidelines and process within timelines.
• Collaborate with multidisciplinary teams and adhere to policies and regulations.
• Conduct comprehensive assessments, develop and document care plans, and coordinate activities to ensure continuity of care.
• Monitor and revise care plans to meet desired outcomes.
• Engage with beneficiaries, families, providers, and community resources throughout case management.

Work Schedule

Monday - Friday, 8-hour shifts aligned to state of residence:

• Pacific: 9 am - 6 pm PT
• Mountain: 10 am - 7 pm MT
• Central: 11 am - 8 pm CT
• Eastern: 11 am - 8 pm ET

Qualifications

Required

• Active RN license in residence with multi-state privileges or ability to obtain them.
• 3+ years 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 navigating multiple systems.
• US citizenship and ability to obtain Federal Security Clearance (DOD preferred).
• Private home office environment.

Preferred

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

We are an equal opportunity employer. To view total rewards, visit this link. The salary range is $75,000 - $90,000, depending on experience and location. Other benefits include bonuses, PTO, and region-specific perks. We comply with privacy and anti-fraud policies. AI may be used in recruiting, with candidates able to opt out. Apply now.