Remote Utilization Management/Review Nurse
Remote Utilization Management/Review Nurse Location: Remote (Eligible in Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, Ohio, Oklahoma, Pennsylvania, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming) Schedule: Monday-Friday, 8:00 AM - 5:00 PM Employment Type: Full-Time (Contract; potential for conversion)
About the Role
The Episodic Care Manager is responsible for reviewing and evaluating member cases to ensure medical necessity and appropriate utilization of healthcare services. This role applies clinical expertise, regulatory knowledge, and critical thinking to support high-quality, compliant care decisions while collaborating with providers and internal teams.
Key Responsibilities
Clinical Evaluation & Review
- Receive and manage assigned cases across various member services (e.g., inpatient, outpatient, durable medical equipment).
- Review and evaluate cases for medical necessity using established medical policies, benefits, and care guidelines.
- Complete work in accordance with established timelines, productivity standards, and quality/compliance requirements.
- Provide required notifications to members and/or providers in alignment with regulatory standards.
- Determine when cases require escalation for secondary review by a Medical Director (MD), particularly for potential denials.
- Coordinate peer-to-peer reviews with providers when clinical criteria are not met, as needed.
Collaboration & Documentation
- Communicate and collaborate effectively with internal teams and external partners, including clinicians and Medical Directors.
- Accurately document all review outcomes, ensuring clarity and completeness of clinical rationale.
- Analyze and interpret clinical information to support decision-making.
- Summarize clinical findings against established criteria to assist Medical Directors in review processes.
Qualifications & Requirements
- Licensure:
- Active RN with at least 3 years of clinical experience, OR
- Active LPN with at least 5 years of clinical experience
- For Behavioral Health roles, other relevant clinical licensure may be considered with 3+ years of experience
- Must maintain a valid and unrestricted clinical license (North Carolina or compact multistate licensure required).
Preferred Qualifications
- Experience in utilization review, managed care, or medical necessity review
- Experience with Medicaid/Medicare Claims
- Behavioral health experience (especially inpatient or adolescent care, if applicable)
- Strong analytical, documentation, and communication skills
- Ability to work independently while collaborating within a team environment
Compensation
Salary Range: $65,000 - $75,000 with company subsidized medical, dental, and vision benefits Remote Skills: Analysis Skills, Clinical Assessment, Clinical Competency, Clinical Information, Clinical Medicine, Clinical Outcomes, Clinical Practices/Protocols, Clinical Support, Clinical Trial, Communication Skills, Customer Escalations, Decision Support, Documentation, Durable Medical Equipment, Healthcare, Licensed Practical Nurse/Licensed Vocational Nurse, Managed Care, Medicaid, Medical Assistance, Medicare, Nursing, Outpatient Care, Patient Care, Patient Care Denials, Policy Development, Registered Nurse (RN), Regulatory Compliance, Utilization Management About the Company: Zp Group Llc