Utilization Review Nurse

Job Title: Registered Nurse- Utilization Review Location: Remote Term: 8+ Months (Possible Extension) Schedule: Mon- Fri 8a- 5pm Local time Start Date: Jan 2026 Basic function: This position is responsible for ensuring compliance of the Utilization Management (UM) and Quality Review (QR) functions performed by the Medical Groups/IPAs participating in the networks of client’s HMOs. Evaluates the need for, designs, and implements educational seminars for Medical Groups/IPA staff, assists in benefit determinations, and provides support on transplant requests, benefit terminations and Individual Benefit Management Program (IBMP) cases. Essential Functions: 1. Reviews and evaluates UM/QR plans for prospective and existing Medical Groups/IPAs in the HMO networks. Prepares reports on findings and communicates outcomes to Medical Groups/IPAs and HMO management. 2. Communicates contractual requirements to medical groups, IPAs, and contract management firms, corporate headquarters including but not limited to utilization management, quality review, clinical, and non-clinical quality improvement. 3. Monitors UM activities of Medical Groups/IPAs to measure adherence to HMO UM/QR standards by conducting annual UM/QR audits. Evaluates results, prepares reports on findings, and communicates outcomes to Medical Groups/IPAs and HMO management. 4. Oversees the development and implementation of corrective action plans for deficient Medical Groups/IPAs as a result of Utilization Management statistics, non-compliance with UM policies and procedures, UM/QR plan reviews, and UM/QR audits. Coordinates with Corporate Audit department regarding corporate site audits and related corrective action plans. Performs follow-up reviews, additional on-site visits, and audits as needed. 5. Designs and implements in-services, seminars, and special presentations which promote the UM/QR process in order to provide educational support to Medical Groups/IPAs. Travels to medical groups and IPAs for audits and in-services. 6. Prepares cost analyses and makes recommendations to the Medical Director(s) on extra contractual benefit requests. Communicates decision to Medical Group/IPA and monitors usage of approved extra contractual benefits. 7. Provides necessary administrative support to assist Medical Groups/IPAs with unusual benefit requests, transplant cases, benefit terminations, IBMP cases, and other special issues. Coordinates activities of support staff. 8. Assists management with the annual review and revision of UM/QR standards and audit tools to ensure compliance with NCQA and Client’s HMO requirements. 9. Works in close partnership with Network Consultants to develop strategies which will improve overall Medical Group/IPA performance and promote positive outcomes. Coordinates the transition of care for new and existing members who are currently undergoing a course of evaluation or medical treatment. 10. Communicates trends and overall program performance to management. 11. Participates on various related committees as necessary. 12. Communicate and interact effectively and professionally with co-workers, management, customers, etc. 13. Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies. 14. Maintain complete confidentiality of company business. 15. Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested. Job requirements: 3 years clinical experience with 2 years’ experience in utilization review, quality assurance, or statistical research. Clinical knowledge, knowledge of the UM/QR process, and knowledge of managed care principles. Analytical, verbal and written communications skills. Thanks in advance for your time and consideration, please feel free to provide a current version of your resume. I look forward to hearing from you! Apply tot his job Apply To this Job