Utilization Management Nurse, RN (Remote)

The Utilization Management Nurse, RN is responsible for conducting prospective, concurrent, and retrospective reviews of medical referrals to ensure regulatory compliance and appropriate use of nationally recognized utilization management criteria. This role involves collaborating with Medical Directors, drafting denial language, and translating medical terminology into lay language to support member care and quality initiatives. The position requires a strong understanding of clinical nursing practice, medical necessity standards, and state regulatory requirements.