Utilization Management Nurse, RN

Job Description

Location: Remote (US-based)

We are hiring for a Utilization Management Nurse, RN with a regional managed care organization administering commercial, Medicare Advantage, and Medicaid plans across multiple states. This position is a full-time, direct hire opportunity.

Responsibilities

• Conduct prospective, concurrent, and retrospective authorization reviews using InterQual or MCG criteria
• Evaluate inpatient level-of-care requests and continued stay reviews against evidence-based guidelines
• Approve, pend, or refer cases to Medical Director for final determination
• Complete peer-to-peer calls with attending physicians and specialists to discuss clinical findings
• Document clinical rationale for each review decision in the UM platform with precision and completeness
• Track census and flag cases approaching benefit exhaustion for timely discharge planning
• Coordinate with case management and discharge planning teams on complex or high-acuity cases
• Apply state and federal UM timelines accurately to avoid compliance exposure
• Identify patterns in unnecessary utilization and escalate to quality or medical leadership

Qualifications

• Active unrestricted RN license; compact license strongly preferred
• Minimum three years of clinical nursing experience in an acute care setting
• One or more years of utilization management, utilization review, or case management experience
• Proficiency with InterQual or MCG criteria application
• Understanding of Medicare, Medicaid, and commercial authorization workflows
• Strong documentation skills and comfort with UM-specific software platforms
• Ability to manage a high-volume review queue with accuracy and regulatory timeliness

Schedule

Fully remote within the US. Standard business hours, Monday through Friday, with occasional on-call rotation for weekend coverage.

Salary Range: The salary range for this position is approximately $75,000 – $98,000 annually ($36.06 – $47.12 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.