North Carolina Licensed Utilization Nurse

To support its clients, the full-time North Carolina Licensed Utilization Nurse will perform medical necessity and benefit review requests remotely, ensuring compliance with national standards and contractual requirements. Key responsibilities Conducts clinical utilization reviews using evidence-based guidelines and internal policies Collaborates with healthcare partners to ensure timely review of services and care Identifies potential quality of care issues and communicates determinations to providers and members Required qualifications Current Licensed Practical Nurse (LPN) with active and unrestricted state licensure 2+ years of experience in a Utilization Management team within a managed care setting Proficient in Microsoft Office applications Experience with inpatient and outpatient reviews, including Behavioral Health and elective surgical cases Working knowledge of URAC and NCQA standards