Utilization Management Nurse Consultant

We are seeking an experienced Registered Nurse to join a remote Utilization Management team in a non-bedside clinical role. You will use your nursing expertise and evidence-based clinical criteria to review cases, assess medical necessity, and support appropriate coverage decisions. Working closely with healthcare providers and interdisciplinary teams, you will help ensure members receive the right care in the right setting at the right time. Your clinical judgment will contribute to effective prior authorization decisions, improved healthcare quality, and better member outcomes. You will also serve as a trusted clinical resource, helping stakeholders navigate complex cases and treatment planning. This opportunity is ideal for a detail-oriented nursing professional who wants to apply their clinical knowledge in a structured, collaborative, and quality-focused remote environment.

• Active, unrestricted Registered Nurse (RN) license in the state of residence, as specified in the role requirements.

• Minimum of 3 years of professional RN experience.

• Associate Degree in Nursing (ADN) required; a Bachelor of Science in Nursing (BSN) is preferred.

• Strong clinical assessment, critical thinking, problem-solving, and decision-making skills.

• Ability to interpret clinical information, apply evidence-based criteria, and make sound utilization management decisions.

• Proficiency with Microsoft Office applications, including Outlook, Teams, and Excel.

• Ability to work Monday through Friday, from 9:00 AM to 5:30 PM in the local time zone, with occasional schedule flexibility due to the 24/7 nature of utilization management operations.

• Previous experience in utilization management, prior authorization, care management, or managed care is preferred.

• At least 1 year of Medical-Surgical Nursing experience is preferred.

• Familiarity with MedCompass or similar utilization management platforms is an advantage.

• Ambulatory surgery or outpatient clinical experience is beneficial.

• Strong digital skills, including the ability to navigate multiple monitors, applications, calendars, email systems, and virtual meeting platforms simultaneously.

• Experience with Microsoft 365 tools, including Teams, Outlook, Word, Excel, and PowerPoint, or equivalent applications.

• Ability to securely access healthcare systems and applications, including VPNs, and follow established data protection procedures.

• Basic technical troubleshooting skills, including resolving connectivity and application issues, with a willingness to learn new technologies.

• For remote work, candidates must have a direct wired internet connection with minimum speeds of 25 Mbps download and 3 Mbps upload; Wi-Fi and satellite connections are not accepted.

• Must maintain a dedicated, private workspace that complies with HIPAA and applicable security requirements.

• Must be able to work from the confirmed state and city of residence and maintain the required internet speeds and remote-work standards.

• Company-provided equipment includes a computer, monitor(s), keyboard, and headset; employees are responsible for providing appropriate workspace furniture.