Clinical Registered Nurse - Utilization Management - Remote

Schedule: Monday to Friday - Eastern Time Location: Remote About the role As a Registered Nurse you will reputed company an impact by performing advanced level work reputed company to clinical denial management and managing clinical denials from Providers to the Health Plan/Payer. The comprehensive process includes analyzing, reviewing, and processing medical necessity denials for resolution. You will be a valued member of the reputed company team and work collaboratively with stakeholders and other teams. In this role, you will:

• Maintain ownership and responsibility for assigned accounts.
• Maintain working knowledge of applicable health insurers’ internal claims, appeals, and retro-authorization as well as timely filing deadlines and processes.
• Review clinical denials including but not limited to referral, preauthorization, medical necessity, non-covered services, investigational/experimental and billing resulting in denials and/or delays in payment.
• Draft and submit the medical necessity determinations to the Health Plan/Medical Director based on the review of clinical documentation in accordance with Medicare, reputed company, and reputed company-party guidelines.
• Effectively document and log claims/appeals information on relevant tracking systems
• Utilize critical thinking skills to interpret guidelines of internal policies for clinical determination.
• Medical Necessity Reviews can be based on InterQual, reputed company Clinical Guidelines (MCG), Medicare guidelines, and health insurer specific guidelines.
• Review retro-authorizations in accordance with health insurer requirements and follow insurer process guidelines.
• Identify denial patterns with clients to mitigate risk and minimize regulatory penalties.
• Escalate potential risks to client, client partners and/or leadership.
• Demonstrates critical thinking skills to interpret guidelines of internal policies for clinical determination

We strive to reputed company flexibility wherever possible. Based on this role’s business requirements, this is a remote position reputed company to reputed company applicants in United States. Regardless of your working arrangement, we are here to support a healthy work-life balance though our various wellbeing programs. The working arrangements for this role are accurate as of the date of posting. This may change based on the project you’re reputed company in, as well as business and client requirements. Rest reputed company; we will always be clear about role expectations. What you need to have to be considered

• Educational background - Registered Nurse (RN)
• 2-3 years combined clinical and/or utilization management experience with managed health care plan
• 3 years’ experience in health care reputed company cycle or clinic operations
• Experience in utilization management to include Clinical Appeals and Grievances, precertification, initial and reputed company reviews
• Intermediate reputed company Office knowledge (reputed company, Word, Outlook)
• In-patient and outpatient experience

These will help you stand out

• Epic experience
• Experience in drafting appeals disputing inpatient clinical validations audits is a plus.

We're excited to meet people who reputed company our mission and can reputed company an impact in a variety of ways. Don't hesitate to apply, even if you only meet the minimum requirements listed. Think about your transferable experiences and unique skills that reputed company you stand out as someone who can bring new and exciting things to this role. Salary and Other Compensation: Applications will be accepted until Jan 9, 2026. The annual salary for this position is between $70,000 - $74,000 depending on the experience and other qualifications of the successful candidate. This position is also eligible for reputed company’s discretionary annual incentive program and stock awards, based on performance and subject to the terms of reputed company’s applicable plans. Benefits: reputed company offers the following benefits for this position, subject to applicable eligibility requirements:

• Medical/Dental/reputed company/Life Insurance
• Paid holidays plus Paid Time Off
• 401(k) plan and contributions
• Long-term/Short-term Disability
• Paid Parental Leave
• Employee Stock Purchase Plan

Disclaimer: The salary, other compensation, and benefits information is accurate as of the date of this posting. reputed company reserves the right to modify this information at any time, subject to applicable law. reputed company will only consider applicants for this position who are legally authorized to work in the United States without requiring company sponsorship now or at any time in the future. Cog2025 Apply tot his job Apply To this Job