Utilization Management RN — Remote Option

Hometown Health; Reno, Northern (NV, KY); Hybrid; USD 85,000 - 110,000; Full time

Job summary

Hometown Health is seeking a Utilization Management RN to consistently apply the utilization management process for CMS requirements and NCQA standards. You will evaluate medical necessity for prior authorizations, admissions, and concurrent reviews, in collaboration with the Medical Director or CMO.

The role requires coordination with hospital staff, discharge planning support, and timely determinations within cost and quality targets. Remote or virtual options may be available per policy.

Qualifications

• Ability to read, write, speak, and understand English sufficiently to perform job duties safely and effectively.
• Bachelor of Science in Nursing Degree preferred.
• Minimum two years of clinical experience in an in-patient or outpatient setting.
• Two to three years of managed care utilization management or case management recommended.

Responsibilities

• Apply medical necessity guidelines to prospective and concurrent reviews.
• Coordinate with interdisciplinary team to determine appropriate level of care.
• Document all medical necessity determinations and communications in the utilization review system.
• Identify and communicate avoidable days, denials, and utilization issues.
• May cross-train within utilization roles to cover vacations or vacancies.

Skills

Interpersonal communication

Critical thinking

Problem solving

Time management

Written communication

Education

Bachelor of Science in Nursing

Tools

MS Office Suite

Job description

Hometown Health is seeking a Utilization Management RN to consistently apply the utilization management process for CMS requirements and NCQA standards. You will evaluate medical necessity for prior authorizations, admissions, and concurrent reviews, in collaboration with the Medical Director or CMO.

The role requires coordination with hospital staff, discharge planning support, and timely determinations within cost and quality targets. Remote or virtual options may be available per policy.