Behavioral Health RN

Position Overview:
The Utilization Management (UM) Nurse assesses healthcare services to ensure optimal outcomes, cost-effectiveness, and compliance with state and federal regulations. This role involves analyzing clinical service requests, conducting prior authorization reviews, and collaborating with multidisciplinary teams to promote the Care Model.

*Must have BH service background and/or MCO experience in UM*

Must reside in one of the following states: AZ, FL, GA, ID, IA, KY, MI, NE, NM, NY (outside greater-NYC), OH, TX, UT, WA (outside greater-Seattle), WI.

*Eastern time zone is preferred but not required*

Key Responsibilities:

• Service Assessment & Compliance:
• Evaluate healthcare services to guarantee optimal patient outcomes and adherence to all regulatory standards.
• Clinical Review & Authorization:
• Analyze clinical service requests against evidence-based guidelines (e.g., MCG).
• Conduct prior authorization reviews, determining financial responsibility for both Healthcare and its members.
• Process requests efficiently within required timelines, completing 15–20 authorizations daily.
• Benefit & Eligibility Identification:

Confirm eligibility and benefits for requested treatments or procedures. Refer complex prior authorization requests to Medical Directors as needed. Request additional information from members or providers in a consistent, efficient manner. Work closely with multidisciplinary teams to implement the company Care Model. Make appropriate referrals to other clinical programs when necessary. Follow all UM policies and procedures consistently.

Requirements:

• Education & Licensure:
• Active RN, LPN, LCSW or LPC.
• Technical Skills:
• Proficient in utilizing systems like QNXT/UMK2 (preferred).
• Experience with MCG guidelines (preferred).
• Day to Day responsibilities:
• Reviewing provider submissions to request prior service authorizations. Reviewing those requests for Medical Necessity.

Job Types: Full-time, Contract

Pay: $42.01 per hour

Expected hours: 40 per week

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Application Question(s):

• Strong inpatient and outpatient medical and hospital analytical experience is needed
• Excellent computer multi-tasking skills and good productivity is essential for this fast-paced role.
• Must have prior authorization experience
• Must be able to work East Coast time zone or Central Time Zone

Experience:

• Utilization management: 2 years (Required)

License/Certification:

• RN or LPN license (Required)

Work Location: Remote

Salary : $42