Utilization Management RN in United States at Jobgether

This position is posted by Jobgether on behalf of a partner company. We are currently looking for a Utilization Management RN in the United States.

This role is central to ensuring members receive the most appropriate, effective, and timely care by applying clinical expertise to utilization review processes. You will evaluate medical necessity using established criteria, policies, and clinical guidelines while coordinating closely with providers, members, and interdisciplinary teams. Operating in a fully remote environment, you will contribute to care decisions that directly impact patient outcomes and healthcare quality. The position requires strong clinical judgment, attention to detail, and the ability to navigate complex care scenarios. You will collaborate within a structured utilization management framework aligned with organizational goals and regulatory standards. This is a highly impactful role at the intersection of clinical care, coordination, and health plan operations.

In this role, you will apply clinical nursing expertise to review and evaluate treatment requests, ensuring services meet medical necessity criteria and align with established guidelines and policies. You will collaborate with providers and members to facilitate appropriate care pathways and support timely decision-making. Key responsibilities include:

• Conducting utilization reviews and applying clinical criteria to determine appropriateness of services and levels of care
• Coordinating and communicating with providers, members, and internal teams to support care planning and treatment decisions
• Documenting and maintaining accurate clinical assessments and utilization determinations in accordance with regulatory standards
• Supporting care coordination efforts and escalating complex cases as needed
• Participating in departmental processes aligned with organizational and compliance requirements
• Contributing to consistent application of utilization management policies and procedures

This role requires a strong clinical foundation in acute care nursing and the ability to apply clinical judgment in a structured review environment. Candidates should be comfortable working independently in a remote setting while maintaining accuracy and compliance in all documentation and decisions.

• Active Registered Nurse (RN) license in a compact state, with eligibility for additional licensure as required
• Minimum 3+ years of acute care experience (Medical-Surgical, Cardiac, Pulmonary, or Critical Care)
• Strong clinical assessment and critical thinking skills in high-acuity environments
• Ability to interpret medical records, clinical criteria, and utilization guidelines
• Preferred experience in utilization management, health plan, Medicare, or Medicaid environments
• BSN or bachelor’s degree in nursing or related field preferred
• Strong communication, collaboration, and documentation skills
• Ability to work independently, manage workload, and adapt to rotating schedules including holidays if required

• Competitive annual salary ranging from $71,100 to $97,800, based on experience and location
• Performance-based bonus incentive plan eligibility
• Medical, dental, and vision insurance coverage
• 401(k) retirement savings plan
• Paid time off, including holidays, parental leave, and volunteer time
• Short-term and long-term disability coverage
• Life insurance and additional wellness benefits
• Remote work flexibility with required home office standards and support equipment where applicable