Utilization Management RN Reviewer - Remote Options

Lifetime Workforce Solutions, LLC; United States; Hybrid; USD 62,000 - 118,000; Full time

Job summary

CDPHP is seeking a Utilization Management professional to coordinate and monitor behavioral and physical health services for members. You will work with Medical Director and Case Management, participate in on-call shifts, and ensure compliance with regulatory standards.

Responsibilities include performing clinical reviews, ensuring medical necessity, and collaborating with hospitals and providers to close gaps in care. Strong communication and multi-tasking are essential for success.

Qualifications

• Associates degree and NYS RN license required; Bachelor’s degree preferred.
• Minimum of three years clinical experience; Utilization Management experience preferred.
• Proficient with Microsoft Office; understands coding standards.
• Strong written and verbal communication; able to multitask independently.

Responsibilities

• Perform pre-service, concurrent, and post-service reviews for care appropriateness.
• Communicate with members and providers to obtain information and assess medical necessity.
• Collaborate with hospital, home care, care management to ensure no gaps in care.
• Mentor staff and participate in audits and training.

Skills

Clinical review

Utilization management

Education

Associate degree

Bachelor’s degree

Tools

Microsoft Office

Job description

CDPHP is seeking a Utilization Management professional to coordinate and monitor behavioral and physical health services for members. You will work with Medical Director and Case Management, participate in on-call shifts, and ensure compliance with regulatory standards.

Responsibilities include performing clinical reviews, ensuring medical necessity, and collaborating with hospitals and providers to close gaps in care. Strong communication and multi-tasking are essential for success.