Utilization Management Nurse – Behavioral Health Focus (Remote)

Morgan Stephens; Columbus (OH); Remote; USD 60,000 - 80,000; Full time

Job summary

An established industry player is looking for a dedicated Utilization Management Nurse with a focus on behavioral health services. This role is crucial in reviewing service authorization requests and ensuring timely care for members. The ideal candidate will have a strong background in behavioral health and experience with Managed Care Organizations. You will work collaboratively with various departments to maintain high standards of care and support new team members. If you are passionate about making a difference in healthcare and possess the necessary skills and qualifications, this opportunity is perfect for you.

Qualifications

• Active RN, LPN, LCSW, or LPC license in any U.S. state required.
• 2 years of clinical experience, preferably in hospital nursing.

Responsibilities

• Review provider submissions for prior service authorizations.
• Evaluate medical necessity and appropriate service levels.
• Collaborate with internal departments to ensure continuity of care.

Skills

Behavioral Health services

Utilization Management

Communication skills

Problem-solving skills

Organizational skills

Education

Registered Nursing program

2 years of clinical experience

Tools

Microsoft Office

Electronic documentation systems

InterQual

NCQA standards

Job description

Job Title: Utilization Management Nurse – Behavioral Health Focus (Remote)

Location Requirements:
Candidates must be located in one of the following preferred states: Arizona (AZ), Florida (FL), Georgia (GA), Idaho (ID), Iowa (IA), Kentucky (KY), Michigan (MI), Nebraska (NE), New Mexico (NM), New York (NY – outside greater NYC), Ohio (OH), Texas (TX), Utah (UT), Washington (WA – outside greater Seattle), or Wisconsin (WI).

Time Zone Preference:
Eastern Time Zone is preferred, but not required.

Work Schedule:
Tuesday through Saturday, 8:00 AM – 5:00 PM EST

Compensation:
$40 per hour

Position Type:
Temporary to Permanent

Position Summary:
A Managed Care Organization is seeking a Utilization Management Nurse to review provider-submitted service authorization requests and evaluate medical necessity, with a primary focus on behavioral health services. This position plays a key role in ensuring members receive appropriate and timely care by performing prior authorizations and concurrent reviews.

Day-to-Day Responsibilities:

• Review provider submissions for prior service authorizations, particularly in behavioral health

• Evaluate requests for medical necessity and appropriate service levels

• Provide concurrent review and prior authorization according to internal policies

• Identify appropriate benefits and determine eligibility and expected length of stay

• Collaborate with internal departments, including Behavioral Health and Long Term Care, to ensure continuity of care

• Refer cases to medical directors as needed

• Maintain productivity and quality standards

• Participate in staff meetings and assist with onboarding of new team members

• Foster professional relationships with internal teams and provider partners

Must-Have Requirements:

• Background in Behavioral Health services and/or experience with a Managed Care Organization (MCO) in Utilization Management

Licensure Requirements:

• Active, unrestricted RN, LPN, LCSW, or LPC license in any U.S. state

Required Education and Experience:

• Completion of an accredited Registered Nursing program (or equivalent combination of experience and education)

• 2 years of clinical experience, preferably in hospital nursing, utilization management, or case management

Knowledge, Skills, and Abilities:

• Understanding of state and federal healthcare regulations

• Experience with InterQual and NCQA standards

• Strong organizational, communication, and problem-solving skills

• Proficient in Microsoft Office and electronic documentation systems

• Ability to work independently and manage multiple priorities

• Professional demeanor and commitment to confidentiality and compliance with HIPAA standards

• Team-oriented with the ability to build and maintain positive working relationships