- Location: Little Rock , Arkansas
- Type: Contract
- Job #11535
- Salary: $35
Location Type: On-Site
Location: Remote or Hybrid (United States)
Job Type: Full-Time
We are seeking an experienced Utilization Management Nurse (RN) to join a healthcare organization focused on delivering high-quality, cost-effective care. In this role, you will perform clinical reviews for inpatient and outpatient services, ensuring appropriate levels of care and medical necessity through evidence-based guidelines and regulatory standards.
The Utilization Management Nurse works collaboratively with providers and internal teams to support quality outcomes, member safety, and responsible utilization of healthcare services.
Perform clinical review of prior authorizations, benefit inquiries, network exceptions, and inpatient/outpatient medical and surgical services.
Assess appropriateness of care and medical necessity using evidence-based criteria, clinical guidelines, and organizational policies.
Collaborate with healthcare providers and internal stakeholders to promote quality, accessibility, and cost-effective care delivery.
Conduct and document comprehensive case reviews for services including diagnostics, procedures, surgeries, and out-of-network requests.
Screen, organize, and prioritize determination requests according to regulatory mandates and timelines.
Ensure compliance with URAC standards, state regulations, and nursing scope of practice.
Support care coordination and cost containment initiatives while maintaining member-focused clinical judgment.
Remain current on medical procedures, healthcare delivery trends, and organizational standards.
Manage inbound/outbound calls and work queues efficiently within required turnaround times.
Perform additional duties as assigned.
Active, unrestricted Registered Nurse (RN) license in good standing (state of practice required).
Minimum 4 years of clinical nursing experience in one or more of the following settings:
Strong critical thinking and sound clinical judgment skills.
Excellent verbal and written communication abilities.
Detail-oriented with strong documentation and interpretation skills.
Proficient in Microsoft Office (Word, Excel, Outlook) and comfortable navigating multiple systems.
Ability to work independently while building collaborative relationships across teams.
