Utilization Management Nurse - Impactful Care & Efficiency

SIHO Insurance Services; United States; Remote; USD 85,000 - 120,000; Full time

Job summary

SIHO Insurance Services seeks a licensed Registered Nurse for the Utilization Management Nurse role. You will perform prospective, concurrent, and retrospective reviews to ensure medical necessity and CMS guideline adherence, coordinating with members and providers to determine coverage decisions.

The role requires strong clinical judgment, efficient time management in a fast-paced environment, and proficiency with Microsoft Office.

Qualifications

• RN with current, unrestricted license in primary state of employment.
• Prior UM or health plan experience preferred.
• Ability to work in a fast-paced environment while maintaining quality.
• Self-directed organization and prioritization skills, and independent time management.
• Excellent verbal and written communication skills.
• Microsoft Office experience: Outlook, Word, Excel.

Responsibilities

• Pre-service, concurrent, and post-service review of medical necessity per guidelines.
• Interact with member, provider, and care team to complete reviews efficiently.
• Coordinate with SIHO Medical Director to ensure timely determinations.
• Document the review process accurately in the established system.
• Ensure determinations are rendered within contractual and CMS turnaround times.
• Identify and report Potential Quality of Care concerns and Fraud, Waste and Abuse.

Skills

Utilization Review experience

Strong communication

Time management

Microsoft Office proficiency

Education

Registered Nurse license (unrestricted)

Tools

Microsoft Office (Outlook, Word, Excel)

Job description

SIHO Insurance Services seeks a licensed Registered Nurse for the Utilization Management Nurse role. You will perform prospective, concurrent, and retrospective reviews to ensure medical necessity and CMS guideline adherence, coordinating with members and providers to determine coverage decisions.

The role requires strong clinical judgment, efficient time management in a fast-paced environment, and proficiency with Microsoft Office.