Connecticut Licensed Utilization Management RN

Working remotely on a full-time basis, the Connecticut Licensed Utilization Management RN will manage medical necessity reviews, authorization compliance, and reimbursement optimization while serving as a liaison between providers and payers. Key Responsibilities Review documentation against payer policies and medical necessity criteria, identifying gaps and guiding improvements Interpret payer requirements and advise providers on compliance and discrepancies between authorized and performed services Prepare clinical summaries and medical necessity rationales for appeals, supporting provider preparation for discussions and identifying ways to prevent recurring denials Required Qualifications Licensure as a Registered Nurse in the State of Connecticut or eligibility for Connecticut licensure Experience in utilization management, case management, prior authorization, or related healthcare operations preferred Knowledge of medical necessity criteria, payer guidelines, and healthcare reimbursement processes Strong critical thinking and clinical assessment skills Proficiency with electronic health records and payer portal systems