Utilization Management Registered Nurse - Behavioral Health

Job Overview

This remote, full-time role involves telephonic coordination and delivery of clinical behavioral health services aimed at supporting consumers' wellness and recovery goals. The incumbent will conduct prospective, concurrent, and retrospective reviews of inpatient, outpatient, ambulatory, and ancillary services to verify medical necessity, appropriate length of stay, intensity, and level of care. The position also entails managing appeal requests and coordinating care plans across the healthcare continuum by leveraging clinical expertise.

Key Responsibilities

• Collaborate using clinical knowledge to assess, plan, implement, coordinate, monitor, and evaluate health service options for members.
• Review and authorize various service requests including elective, urgent, emergency, and ancillary, utilizing approved clinical protocols and interacting with healthcare providers to recommend alternative treatments or service levels as needed.
• Perform analyses and prepare documentation for retrospective reviews and appeals in compliance with regulatory and accreditation standards.
• Coordinate discharge planning activities by communicating with internal and external stakeholders.
• Investigate and resolve issues such as benefits, member eligibility, non-authorized services, and care coordination.
• Provide targeted education to providers regarding policies, procedures, and benefits.
• Facilitate communication with providers to support care delivery.
• Identify members for referral to integrate additional services or programs and promote healthcare quality and benefit utilization.
• Offer clinical expertise to support utilization and benefit management functions within the organization.

Qualifications

• Current and unrestricted Registered Nurse license is mandatory; Case Management certification preferred.
• A minimum of two years acute clinical nursing experience is required.
• Preferably one or more years of experience in a health insurance plan or managed care environment.
• At least one year of behavioral health clinical experience, along with one year of managed care utilization management experience, is expected.
• Strong verbal and written communication, customer service, and interpersonal skills.
• Proficient with Microsoft Office and clinical criteria application for medical necessity and patient management.
• Knowledgeable about medical practices, alternative care settings, member benefits, regulatory standards, and accreditation requirements.

Work Environment & Additional Information

• This role primarily involves sitting or standing for extended computer work, occasionally moving around an office setting.
• The candidate must be able to work across multiple time zones and may occasionally travel per company needs.
• Abilities related to vision including close, color, peripheral, and depth perception, and focus adjustment are necessary.
• An emphasis on continuous learning and obtaining or maintaining certifications is supported.
• The employer complies with the Americans with Disabilities Act and conducts pre-employment background checks.
• Equal opportunity employer encouraging candidates from diverse backgrounds.
• Compensation ranges US $65,000 to $85,000 annually, determined by qualifications and experience.