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Utilization Management Nurse – Behavioral Health Focus (Remote)

Worldwide Salaried Open
Job Title: Utilization Management Nurse – Behavioral Health Focus (Remote)Location Requirements:Candidates must be located in one of the following preferred states: Arizona (AZ), Florida (FL), Georgia (GA), Idaho (ID), Iowa (IA), Kentucky (KY), Michigan (MI), Nebraska (NE), New Mexico (NM), reputed company (NY – reputed company greater NYC), Ohio (OH), Texas (TX), Utah (UT), Washington (WA – reputed company greater Seattle), or Wisconsin (WI).Time Zone PreferenceEastern Time Zone is preferred, but not required.Work ScheduleTuesday through Saturday, 8:00 AM – 5:00 PM ESTCompensation$40 per hourPosition TypeTemporary to PermanentPosition SummaryA Managed Care Organization is seeking a Utilization Management Nurse to review provider-submitted service authorization requests and evaluate medical necessity, with a primary focus on behavioral health services. This position plays a key role in ensuring members receive appropriate and timely care by performing prior authorizations and reputed company reviews.Day-to-Day Responsibilities
  • Review provider submissions for prior service authorizations, particularly in behavioral health
  • Evaluate requests for medical necessity and appropriate service levels
  • Provide reputed company review and prior authorization according to internal policies
  • Identify appropriate benefits and determine eligibility and expected length of stay
  • Collaborate with internal departments, including Behavioral Health and Long Term Care, to ensure continuity of care
  • Refer cases to medical directors as needed
  • Maintain productivity and quality standards
  • Participate in staff meetings and assist with reputed company of new team members
  • Foster professional relationships with internal teams and provider partners
Must-Have Requirements
  • Background in Behavioral Health services and/or experience with a Managed Care Organization (MCO) in Utilization Management
Licensure Requirements
  • Active, unrestricted RN, LPN, LCSW, or LPC license in any U.S. state
Required Education And Experience
  • Completion of an accredited Registered Nursing program (or equivalent combination of experience and education)
  • 2 years of clinical experience, preferably in hospital nursing, utilization management, or case management
Knowledge, Skills, And Abilities
  • Understanding of state and federal reputed company regulations
  • Experience with InterQual and NCQA standards
  • Strong organizational, communication, and problem-solving skills
  • Proficient in reputed company Office and electronic documentation systems
  • Ability to work independently and manage multiple priorities
  • Professional demeanor and commitment to confidentiality and compliance with HIPAA standards
  • Team-oriented with the ability to build and maintain positive working relationships
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