Utilization Management - Clinical Nurse - Work from Home!

Utilization Management - Clinical Nurse - Work from Home! Utilization Management - Clinical Nurse - Work from Home! Get AI-powered advice on this job and more exclusive features. Direct message the job poster from BroadPath Global Talent Attraction and Branding Specialist Lead @ BroadPath | Employee Training, Customer Service, Recruiting, Employee Engagement BroadPath is seeking a highly motivated and results-oriented UM Clinical Nurse to join our team. As the UM Clinical Nurse, you will be responsible for precertification of inpatient hospitalizations and outpatient procedures requiring authorization. Conducts telephonic and concurrent review of hospitalizations and extended outpatient treatments, applying clinical judgment, utilization management principles, and medical necessity criteria while ensuring regulatory compliance. Responsibilities Analyze clinical information, treatment plans, and regulatory guidelines for authorization requests Apply clinical decision-making to assess acuity and treatment appropriateness Create case summaries for requests not meeting medical necessity criteria and collaborate with medical directors Research clinical guidelines and stay current on Medicaid manual changes Evaluate discharge planning risks and facilitate appropriate continuity of care Meet regulatory timelines for assessments, decisions, and communications Ensure timely processing of all denial determinations according to regulations Document due process and attempt to gather adequate clinical information Notify providers of denials, offering peer-to-peer conversations and communicating appeal processes Distributed denial letters to all involved parties within regulatory timeframes Hold discussions with providers regarding guideline application and coverage determinations Document all provider interactions in the authorization system Promote provider satisfaction through education on managed care and authorization requirements Serve as liaison between providers and facilities to promote quality service and care Screen and identify potential members for case management programs Recommend care planning based on projected treatment course and prognosis Coordinate with hospital staff on discharge service packages to reduce readmission risk Prepare cost-benefit analyses for exceptional coverage situations Identify potential quality issues, fraud, or abuse concerns Coordinate with UM Analyst staff on appeals and complaints Ensure compliance with regulatory standards and contractual requirements Participate in quarterly inter-rater reliability reviews Qualifications RN license in an eNLC (Enhanced Nurse Licensure Compact) state with multistate privileges 3+ years Nursing experience 1+ years Utilization Management experience Familiarity with medical terminology, utilization management guidelines, and clinical documentation standards Proficiency in Microsoft Office and experience working with healthcare systems or electronic medical records Strong organizational and time management skills with the ability to work independently Excellent written and verbal communication skills Preferred Qualifications Experience in managed care Experience in pediatrics Diversity Statement At BroadPath, diversity is our strength. We embrace individuals from all backgrounds, experiences, and perspectives. We foster an inclusive environment where everyone feels valued and empowered. Join us and be part of a team that celebrates diversity and drives innovation! Equal Employment Opportunity/Disability/Veterans If you need accommodation due to a disability, please email us at View email address on click.appcast.io. This information will be held in confidence and used only to determine an appropriate accommodation for the application process. BroadPath is an Equal Opportunity Employer We do not discriminate against our applicants because of race, color, religion, sex (including gender identity, sexual orientation, and pregnancy), national origin, age, disability, veteran status, genetic information, or any other status protected by applicable law. Seniority level Seniority level Associate Employment type Employment type Full-time Job function Job function Customer Service Industries Outsourcing and Offshoring Consulting and Medical Practices Referrals increase your chances of interviewing at BroadPath by 2x Sign in to set job alerts for “Registered Nurse” roles. 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