Remote Behavioral Health Utilization Review Nurse

If you're a clinically driven RN or LPN with utilization management experience and a passion for making meaningful coverage decisions, this remote opportunity offers the chance to directly impact member care and outcomes. Join a collaborative team where your expertise in medical necessity review and behavioral health services helps ensure members receive the appropriate level of care.

Location: Remote

Pay Rate: $40-$45/hour

Employment Type: Contingent

Schedule: Monday-Friday, 8:00 AM-5:00 PM

Why This Role Matters

In this role, you will evaluate behavioral health and substance abuse cases to determine medical necessity and authorization eligibility. Your clinical judgment will play a critical role in ensuring members receive the appropriate care while maintaining compliance with established guidelines, policies, and regulatory requirements.

What You'll Do
• Review assigned inpatient, outpatient, and other healthcare service requests for medical necessity using clinical guidelines, policies, and benefit criteria
• Make authorization determinations and provide notifications to members and providers as required
• Communicate with providers to obtain additional clinical information needed to complete reviews
• Coordinate peer-to-peer reviews and facilitate secondary reviews with Medical Directors when appropriate
• Document review outcomes accurately and thoroughly within internal systems
• Analyze and summarize clinical information to support utilization management decisions
• Collaborate with internal clinical and non-clinical teams to ensure timely case resolution
• Manage a caseload of behavioral health and substance abuse reviews across multiple levels of care

What We're Looking For
• A current, up-to-date resume
• Active RN license with at least 3 years of clinical experience, or active LPN license with at least 5 years of clinical experience
• Current and valid NC or Compact Multistate Nursing License
• Experience with utilization management, medical necessity reviews, and authorization determinations
• Experience reviewing behavioral health, substance abuse, or eating disorder cases
• Insurance industry experience and understanding of payer guidelines and processes
• Strong computer skills with the ability to navigate multiple systems simultaneously
• Working knowledge of Microsoft Outlook and other standard business applications
• Excellent communication skills and ability to interact professionally with providers and clinical teams
• Ability to meet compliance requirements

What's In It For You
• Fully remote opportunity with a nationally recognized healthcare organization
• Competitive hourly pay
• Opportunity to utilize and expand your utilization management expertise
• Collaborative environment with ongoing interaction among providers and healthcare professionals
• Meaningful work impacting patient care and healthcare access decisions

Benefits for Manpower Associates (Upon Eligibility)

Upon completion of waiting period associates are eligible for:
• Medical and Prescription Drug Plans
• Dental Plan
• Supplemental Life Insurance
• Short Term Disability Insurance
• 401(k