Utilization Review Nurse (RN) — Elevate Patient Care

Career Center; United States; Remote; USD 70,000 - 100,000; Full time

Benefits offered by this job

Medical/Dental/Vision insurance

Generous PTO and holidays

TeleDoc 24/7/365

Disability plans (short/long-term)

EAP

401K with company match

Referral bonus program

Job summary

American Health Plans, a division of American Health Partners Inc., seeks a Utilization Review Nurse to assess medical necessity and quality of care. You will support the Clinical Services Department and Medical Director, ensuring compliance with regulatory guidelines while coordinating care for plan members.

The role requires RN licensure with UR experience; CCM is a plus. The position offers comprehensive benefits and opportunities to collaborate with nurses and physicians across multiple

Qualifications

• At least 1 year in utilization management with a health plan or hospital UM department using Interqual or MCG
• Broad knowledge of Medicare regulations and guidance
• Trained in UR/URAC and NCQA principles and procedures
• Excellent customer service experience
• Strong medical terminology and CPT/ICD-10/HCPCS knowledge

Responsibilities

• Assess medical necessity, quality of care, and level of care for plan members
• Identify lowest-restriction placement settings based on medical necessity
• Coordinate with providers to gather clinical data
• Apply review criteria to determine medical necessity
• Certify cases meeting criteria and consult when needed
• Refer cases to internal teams (case management, medical) as appropriate
• Meet accreditation, contractual, and regulatory timeframes

Skills

Customer service

Communication

Critical thinking

Independent work

Education

RN license

CCM (preferred)

Job description

American Health Plans, a division of American Health Partners Inc., seeks a Utilization Review Nurse to assess medical necessity and quality of care. You will support the Clinical Services Department and Medical Director, ensuring compliance with regulatory guidelines while coordinating care for plan members.

The role requires RN licensure with UR experience; CCM is a plus. The position offers comprehensive benefits and opportunities to collaborate with nurses and physicians across multiple