Job Description

Job Description

Job Description

Contract (6-12 months) Fully Remote 

Valid unrestricted Registered Nursing License

8-5 M-F MST- Must be willing to work MST hours

Experience: 3-5 years’ utilization management, clinical review experience

Education: Associates Degree in Nursing or Bachelors Degree in Nursing

• Make clinical decisions using approved and accepted plan policies and criteria.
• Determine eligibility and benefit coverage according to member and provider contracts.
• Identify appropriate members for medical or behavioral health case management.
• Respond to requests for authorization of medications or inpatient procedures and services.
• Document and reports potential quality of care or service issues to leadership.
• Perform peer to peer audits to assist with consistency of application of business workflows.
• May provide review according to established criteria for procedural authorization.
• Perform other duties and responsibilities as assigned.
• High degree verbal and written communication
• Independent and critical thinking
• Handle multiple projects simultaneously
• Work well in a team environment

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