Utilization Management Nurse, Outpatient

Job Description

Location: Remote (US-based)

We are seeking a Utilization Management Nurse, Outpatient to support outpatient utilization review and medical necessity determination activities within a national managed care environment. This role is responsible for reviewing outpatient services, applying clinical criteria, coordinating authorization workflows, and supporting appropriate utilization of healthcare resources while maintaining regulatory compliance.

This position is ideal for an experienced RN with utilization management or case management experience who enjoys applying clinical judgment in a structured, remote environment focused on quality, consistency, and timely decision-making.

Responsibilities:

• Conduct prospective, concurrent, and retrospective utilization reviews for outpatient procedures, diagnostics, therapies, and specialty services
• Apply InterQual, MCG, or similar criteria to determine medical necessity and appropriateness of requested services
• Process authorization determinations within required regulatory and organizational turnaround times
• Escalate non-qualifying or complex cases to physician advisors for peer-to-peer review
• Communicate authorization outcomes, denials, and pending review notices to providers, facilities, and members
• Coordinate peer-to-peer review scheduling and clinical communication between providers and physician advisors
• Document utilization review findings, clinical rationale, and authorization activity within the care management platform
• Identify members who may benefit from case management or disease management support and initiate referrals
• Review clinical documentation including physician notes, operative reports, imaging results, and laboratory findings to support determinations
• Maintain compliance with federal, state, payer, URAC, and NCQA utilization management requirements
• Collaborate with interdisciplinary teams to support quality outcomes and appropriate resource utilization
• Monitor workflow productivity, turnaround times, and documentation quality standards

Qualifications:

• Active Registered Nurse (RN) license required; compact licensure preferred
• Minimum of 3 years of clinical nursing experience required
• Backgrounds in acute care, ambulatory care, med-surg, orthopedics, cardiology, oncology, behavioral health, or related specialties preferred
• Minimum of 1–2 years of utilization management, prior authorization, or case management experience preferred
• Experience applying InterQual, MCG, or similar utilization review criteria independently
• Knowledge of managed care regulations including URAC, NCQA, and utilization management compliance requirements
• Experience with care management platforms such as Jiva, HealthEdge, Facets, or TriZetto preferred
• Strong clinical assessment, documentation review, and communication skills
• Ability to work independently within a remote, metrics-driven environment

Schedule:

• Full-time, remote position
  Monday through Friday standard business hours
  Flexible scheduling within operational needs

Salary Range: The salary range for this position is approximately $65,000 – $85,000 annually ($31.25 – $40.87 per hour), based on experience and qualifications.

Interview Process:

• Selected candidates will participate in a multi-step interview process, including an initial screening with TalentLNX followed by interviews with department leadership.

Equal Opportunity Employer: TalentLNX is committed to equal employment opportunity and a diverse, inclusive workforce. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.