Utilization Management Nurse – Behavioral Health Focus (Remote)
About the position A 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 concurrent reviews.
Responsibilities
- Review provider submissions for prior service authorizations, particularly in behavioral health
- Evaluate requests for medical necessity and appropriate service levels
- Provide concurrent 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 onboarding of new team members
- Foster professional relationships with internal teams and provider partners
Requirements
- Background in Behavioral Health services and/or experience with a Managed Care Organization (MCO) in Utilization Management
- Active, unrestricted RN, LPN, LCSW, or LPC license
- 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
- Understanding of state and federal healthcare regulations
- Experience with InterQual and NCQA standards
- Strong organizational, communication, and problem-solving skills
- Proficient in Microsoft 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