Job Description:

• Perform utilization management medical-necessity reviews and level-of-care determinations for requested services
• Apply benefit language, plan documents, medical policies, evidence-based criteria such as MCG and NCCN, and state/federal requirements
• Route requests that do not meet criteria to the Medical Director for secondary clinical review
• Analyze clinical documentation for completeness and identify risk, acuity indicators, inconsistencies, or missing information
• Initiate timely outreach and escalation according to utilization-management workflow
• Prioritize workload based on urgency, regulatory/accreditation time frames, and member impact
• Assist with in-network and benefit-compliant redirection by confirming eligibility, benefits, authorization requirements, and network status
• Support appeals by preparing clinical summaries and documentation and coordinating peer-to-peer/Medical Director discussions
• Document reviews, rationale, criteria or policy citations, communications, and outcomes in designated utilization-management systems
• Meet productivity, quality, accuracy, and turnaround-time standards
• Participate in calibration and quality activities and incorporate feedback
• Maintain HIPAA compliance and confidentiality
• Complete required training and annual competencies
• Cross-train and provide cross-coverage to support team operations and service-level commitments

Requirements:

• Current, unrestricted RN license in the United States or U.S. territory; compact license acceptable where applicable
• Graduate of an accredited nursing program; ADN or diploma required
• BSN preferred
• Minimum 1–2 years of recent clinical experience, such as acute care, med-surg, ICU/ED, or another relevant setting
• Prior utilization review/utilization management experience preferred
• Ability to interpret medical records and apply evidence-based criteria and plan medical policies
• Basic computer literacy upon hire
• Ability to work on multiple screens and proficient typing skills
• Proficiency with Microsoft Word, Microsoft Excel, Outlook, and similar software applications
• Excellent verbal and written communication skills
• Ability to communicate complex or technical information clearly and understand complex information from others
• Ability to work independently and use written resources to solve problems
• Knowledge of medical claims and ICD-10, CPT, and HCPCS coding
• Ability to perform essential job functions safely and successfully, with or without reasonable accommodation
• Ability to maintain regular, punctual attendance
• Ability to sit for 6–8 hours
• Constant computer keyboard and mouse use with repetitive use of both hands
• Occasional to frequent twisting of the neck and occasional bending of the neck and waist
• Weekends required
• Up to 28 hours per week

Benefits:

• Competitive base salary and benefits effective day one
• Comprehensive medical and dental through our own health solutions
• Paid Time Off
• Mental health support
• Retirement planning
• Financial protection
• Professional development with clear career progression and learning budgets
• Mission-driven culture where diverse perspectives drive real impact
• Wellness programs
• Other employee perks
• Full benefits package starting day one