As a Clinical Guide on the Outpatient Utilization Management team, the full-time remote RN Utilization Management Nurse will conduct clinical reviews of outpatient authorization requests, applying evidence-based criteria and health plan policies to ensure members receive appropriate care. Key responsibilities Conduct timely and comprehensive clinical reviews of outpatient authorization requests Determine the appropriateness of requested services and recommend clinically appropriate alternatives Communicate with providers and internal teams to resolve questions and obtain additional clinical documentation Required qualifications An unrestricted RN license with a minimum of 4 years of RN experience At least 3 years of utilization management, utilization review, or prior authorization experience Knowledge of CMS guidelines and Medicare Advantage requirements Experience preparing clinical summaries for physician review Ability to thrive in a fast-paced environment with changing policies and criteria
RN Utilization Management Nurse in workfromhome at Unknown Company
This position is listed as full time and able to be worked remotely.