Utilization Review Nurse: Drive Care Management & Outcomes

WVU Medicine; United States; Remote; USD 75,000 - 95,000; Full time

Job summary

PHH Peak Health Holdings seeks a skilled Registered Nurse with 3 years of healthcare clinical experience to support utilization and care management activities. The role involves building and implementing review processes, ensuring outcome-focused interventions, and collaborating with medical directors to improve member care.

The position requires a current RN license (state or eNLC) and offers a full-time, on-site arrangement in the United States. Occasional weekend/holiday work may be required.

Qualifications

• Current Registered Nurse license (RN) in the state of practice or multi-state license via eNLC.
• Three (3) years of healthcare clinical experience.

Responsibilities

• Assists with building and implementing care management review processes (Prior Authorization, Predetermination, Concurrent and Retrospective reviews) per standards.
• Develops and implements care management reviews according to criteria and policies.
• Ensures interventions maximize member health outcomes.
• Supports Peer-to-Peer Review with Medical Directors to improve services.
• Educates stakeholders to improve processes and build network relationships.
• Collaborates with medical management to identify members needing coaching/case management.
• Works with data to understand outcomes and identify improvement opportunities.
• Committed to lifelong learning and continuous process improvement in Utilization Management.

Skills

InterQual/Milliman Guidelines

Regulatory knowledge

Written and verbal communication

Problem solving

Attention to detail

MS Office

Education

Registered Nurse license (RN)

BSN or ASN; BSN completion within 3 years

Tools

Microsoft Office

Job description

PHH Peak Health Holdings seeks a skilled Registered Nurse with 3 years of healthcare clinical experience to support utilization and care management activities. The role involves building and implementing review processes, ensuring outcome-focused interventions, and collaborating with medical directors to improve member care.

The position requires a current RN license (state or eNLC) and offers a full-time, on-site arrangement in the United States. Occasional weekend/holiday work may be required.