Utilization Management RN – Clinical Review & Cost Control

Youritrecruiter; United States; Remote; USD 85,000 - 120,000; Full time

Job summary

Youritrecruiter UM Nurse role involves conducting clinical reviews to assess medical necessity and efficiency of services requested by providers and members. It supports the health plan’s utilization management aligned with clinical guidelines and accreditation standards.

The position uses criteria such as MCG and InterQual for inpatient, outpatient, and ancillary reviews, aiming to deliver cost-effective, high-quality care and regulatory compliance.

Qualifications

• RN with an active license (state or compact).
• Minimum 3 years in utilization management within health insurance.
• Familiarity with MCG, InterQual, or CMS criteria.
• Knowledge of CMS, NCQA, URAC regulatory standards.

Responsibilities

• Conduct clinical reviews and assess medical necessity, appropriateness, and efficiency of services.
• Support UM functions in line with clinical guidelines and accreditation standards.
• Review inpatient, outpatient, and ancillary services using standard criteria.
• Ensure cost-effective, high-quality care for members.

Skills

Clinical judgment

Critical thinking

Communication skills

EMR proficiency

Education

Associate Degree in Nursing

Bachelor’s Degree in Nursing

Tools

TruCare

GuidingCare

Jiva

Job description

Youritrecruiter UM Nurse role involves conducting clinical reviews to assess medical necessity and efficiency of services requested by providers and members. It supports the health plan’s utilization management aligned with clinical guidelines and accreditation standards.

The position uses criteria such as MCG and InterQual for inpatient, outpatient, and ancillary reviews, aiming to deliver cost-effective, high-quality care and regulatory compliance.