Telephonic Utilization Management & Case Management Operations Registered Nurse | Remote

EXL Service; Pocatello (ID); Remote; USD 75,000 - 90,000; Full time

Job summary

Join a forward-thinking company as a Utilization Management Nurse, where your clinical expertise will help transform healthcare delivery. In this remote role, you'll review authorization requests, conduct assessments, and collaborate with medical professionals to ensure beneficiaries receive the best possible care. With a focus on evidence-based decision-making, you'll play a crucial role in optimizing outcomes and managing costs. This position offers competitive salaries, a supportive telecommuting environment, and the chance to make a significant impact in the healthcare ecosystem.

Benefits

Telecommuting Environment

Competitive Salaries

Health Benefits

Qualifications

• Unrestricted RN license with multi-state privileges.
• 3+ years clinical nursing and 2+ years utilization review experience.

Responsibilities

• Review authorization requests and assess services for optimal outcomes.
• Coordinate care plans and ensure compliance with regulations.

Skills

Clinical Nursing Experience

Utilization Review Experience

Case Management Experience

MS Office Proficiency

Communication Skills

Education

Bachelor’s in Nursing

Tools

MS Office

Teams

SharePoint

Job description

Telephonic Utilization Management & Case Management Operations Registered Nurse | Remote

Company Overview and Culture

EXL (NASDAQ: EXLS) is a leading data analytics and digital operations and solutions company. We partner with clients using a data and AI-led approach to reinvent business models, drive better business outcomes, and unlock growth with speed. EXL harnesses the power of data, analytics, AI, and deep industry knowledge to transform operations for the world's leading corporations in industries including insurance, healthcare, banking and financial services, media, and retail, among others. Founded in 1999, headquartered in New York, with over 55,000 employees across six continents. For more, visit http://www.exlservice.com.

About EXL Health

We leverage Human Ingenuity and domain expertise to help clients improve outcomes, optimize revenue, and maximize profitability across the healthcare ecosystem. Our solutions are driven by technology, data, and analytics, transforming how care is delivered, managed, and paid. We work with over 260 million lives and hundreds of organizations to enhance performance, reduce costs, and improve care quality.

Position Overview

We are seeking a passionate Utilization Management & Complex Case Management Nurse to review and approve authorization requests, and provide comprehensive case management for beneficiaries with complex conditions. Responsibilities include clinical assessments, care planning, and digital outreach to ensure beneficiaries receive appropriate, cost-effective care and support their health goals.

Key Responsibilities

1. Review authorization requests using clinical judgment and evidence-based criteria.
2. Assess services for optimal outcomes, cost-effectiveness, and regulatory compliance.
3. Identify benefits and eligibility for treatments and procedures.
4. Conduct authorization reviews and determine financial responsibility.
5. Approve services or escalate cases to stakeholders.
6. Collaborate with medical directors and other clinical programs.
7. Educate providers on utilization and management processes.
8. Maintain clinical information in management systems.
9. Make independent, evidence-based decisions in ambiguous situations.
10. Process requests within required timelines.
11. Coordinate and monitor care plans, collaborating with beneficiaries and providers.
12. Evaluate and revise care plans to meet goals.
13. Ensure compliance with policies, guidelines, and regulations.

Work Schedule

Monday - Friday, 8-hour shifts aligned with state time zones:

• 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

• Unrestricted RN license in residence state with multi-state privileges or ability to obtain them.
• 3+ years clinical nursing experience.
• 2+ years utilization review experience in health plans or inpatient settings.
• 1+ year case management experience in health plans or inpatient settings.
• Proficiency with MS Office, Teams, SharePoint, and multiple systems.
• U.S. Citizenship and ability to obtain Federal Security Clearance.
• Private, secure home office environment.

Preferred

• Bachelor’s in Nursing from an accredited institution.
• Experience in NCQA and URAC accredited programs.
• Knowledge of hospital acute care, prior auth, utilization review, and guidelines like InterQual or MCG.
• Experience with large health carriers, federal programs (Tricare, Medicare, Medicaid), or commercial insurance.
• Active CCM certification.
• Remote work experience.

Additional Information

We offer competitive salaries ($75,000 - $90,000), benefits, and a telecommuting environment. For more details, visit here.