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Utilization Management Nurse

Job Description

This role involves providing members and healthcare providers with timely prior approval for services and procedures, obtaining necessary medical information to make clinical determinations based on medical policy or criteria. You will complete post-service reviews for medical necessity and support members located in various healthcare facilities, assisting with discharge planning and facilitating referrals to Case Management.

Responsibilities

+ Provide precertification and continued stay reviews for members in acute healthcare facilities, skilled nursing, or home health care admissions.

+ Ensure development and facilitation of timely discharge plans and referrals to Case Management.

+ Work collaboratively with healthcare provider staff to gather medical information and facilitate discharge planning.

+ Influence and negotiate with providers to resolve conflicts and explore alternative treatment settings.

+ Process utilization management requests using clinical knowledge and expertise.

+ Interact with Medical Directors and Physician Reviewers for services not meeting medical criteria.

+ Collaborate with interdisciplinary care teams to coordinate care and meet member needs.

+ Document review processes and decisions accurately and consistently.

+ Communicate approval and denial decisions to members and providers in compliance with regulatory standards.

+ Meet quality assurance and production metrics as established for the utilization management unit.

Essential Skills

+ Registered Nurse (RN) or Licensed Practical Nurse (LPN) with active and unrestricted license in Iowa.

+ 4+ years of diverse clinical experience including critical care, acute care, and outpatient settings.

+ Strong analytic and critical thinking skills with the ability to make independent decisions.

+ Experience in a fast-paced environment with measurable production and quality goals.

+ Excellent verbal and written communication skills.

+ Technical proficiency in systems such as Microsoft Office and clinical documentation platforms.

+ Knowledge of diagnosis and procedure coding systems such as ICD-10, HCPCS, and CPT.

Additional Skills & Qualifications

+ Completion of an accredited nursing program.

+ Experience in Acute Care, Home Health, and Med Surg preferred.

+ Demonstrated commitment to service excellence and patient advocacy.

+ Ability to develop collaborative relationships with peers and stakeholders.

Work Environment

This is a 100% remote role where you will function as part of a multidisciplinary team, continuously improving processes and maximizing health outcomes for members. Candidates must be located in Iowa or South Dakota, or possess a compact license if residing outside these states. The team is collaborative, friendly, and consists of high achievers and self-motivated individuals. Hours are 8 AM - 5 PM CST, and training includes a buddy system for support. The role requires managing metrics with a minimum of 25 reviews daily at a 97% QA review rate.

Must reside in Iowa or South Dakota

Pay and Benefits

The pay range for this position is $33.00 - $40.00/hr.

Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following:

• Medical, dental & vision • Critical Illness, Accident, and Hospital • 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available • Life Insurance (Voluntary Life & AD&D for the employee and dependents) • Short and long-term disability • Health Spending Account (HSA) • Transportation benefits • Employee Assistance Program • Time Off/Leave (PTO, Vacation or Sick Leave)

Workplace Type

This is a fully remote position.

Application Deadline

This position is anticipated to close on Jun 18, 2025.

About Actalent

Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.

The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing due to a disability, please email [email protected] (%[email protected]) for other accommodation options.