Remote RN Utilization Management / Prior Authorization Nurse – Compact Licensed

Job Title: RN Utilization Management Nurse

Location: 100% Remote

Duration: 6+ months (High possibility of extension)

Responsibilities

• Perform concurrent reviews to assess members’ overall health status, evaluate the appropriateness of care, determine medical necessity, and support discharge planning in accordance with utilization management guidelines.
• Review inpatient hospital and rehabilitation cases for Dual Eligible (Medicare and Medicaid) members.
• Document review findings, recommendations, and discharge plans accurately in accordance with utilization management policies and procedures.
• Support timely transitions of care and provide education to providers on utilization management processes and requirements.
• Conduct real-time (concurrent) reviews of inpatient cases to ensure appropriate care delivery and resource utilization.
• Apply medical necessity criteria, including InterQual, MCG, or similar clinical guidelines, to support authorization and care determinations

Key Requirements:

• Active RN License
• 2+ years of Acute Care Nursing experience
• Strong knowledge of medical necessity review and level of care determinations

Years of experience required:

• Minimum 2 years of clinical nursing experience
• 2-4 years of Utilization Management, Prior Authorization and Case Management
• 2+ years of acute care experience required

Education: Graduate of an accredited School of Nursing and Active Registered Nurse (RN) license

License/Certification: RN license required-Compact Licensure.

Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of – Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans