Utilization Management Nurse - Behavioral Health Focus (Remote)

Morgan Stephens; San Antonio (TX); Remote; USD 10,000 - 60,000; Full time

Job summary

A Managed Care Organization is seeking a Utilization Management Nurse to evaluate service authorization requests focused on behavioral health. The role involves collaboration with internal teams and maintaining productivity standards. Candidates must have a nursing license and relevant clinical experience.

Qualifications

• Active, unrestricted RN, LPN, LCSW, or LPC license required.
• 2 years of clinical experience preferred in utilization management or case management.

Responsibilities

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

Skills

Organizational skills

Communication skills

Problem-solving skills

Education

Accredited Registered Nursing program

Tools

Microsoft Office

Electronic documentation systems

Job description

Time Zone Preference :

Pacific or Mountain Time Zone is preferred

Work Schedule :

Tuesday through Saturday, 8 : 00 AM - 5 : 00 PM PST

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

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

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