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Remote Utilization Management Nurse Reviewer

Company: Actalent
Location: Nashville
Posted on: November 23, 2021

Job Description:

Equivalent Experience

The Utilization Management Nurse Reviewer is responsible for day-to-day timely clinical and service authorization review for medical necessity and decision-making.
The Utilization Management Nurse Reviewer works with healthcare providers to ensure appropriate approval of plan benefits. This is accomplished by reviewing clinical information provided to assess medical necessity and the appropriateness of the treatment setting through the application of appropriate policies and criteria (i.e. Milliman). Case assignments may fall in various areas, such as concurrent review of inpatient services, discharge planning, retrospective review, and special needs facilities (SNF), Long Term Acute Care Facilities (LTAC) and Rehabilitation Facilities.


  • Current Active and Unrestricted Nursing License required (Associate Degree, Nursing Diploma or Bachelor's degree in Nursing) (If outside of FL, must be compact, multistate RN license.)
  • 2-3 years' clinical experience in a managed health care plan
  • 2-3 years' utilization management experience in a managed healthcare setting (insurance company)
  • Must be familiar/comfortable with InterQual
  • Required experience in utilization management to include utilization review, concurrent review, discharge planning, appeals experience, transitional care and skilled nursing review.
  • Must pass typing test with 40+ WPMHours:
    Work From Home full-time, equipment and training provided, competitive pay
    No OT
    No weekends
    11AM-7:30PM EST
    6 Month Contract to Hire

    Preferred Qualifications:
    • Bachelor's Degree in Nursing preferred with 3-5 years of clinical experience in Utilization Review
    • Knowledge of Medicaid, Commercial or Medicare Managed Care programs and regulationsAbout Actalent:
      Actalent connects passion with purpose. Our scalable talent solutions and services capabilities drive value and results and provide the expertise to help our customers achieve more. Every day, our experts around the globe are making an impact. We're supporting critical initiatives in engineering and sciences that advance how companies serve the world. Actalent promotes consultant care and engagement through experiences that enable continuous development. Our people are the difference. Actalent is an operating company of Allegis Group, the global leader in talent solutions.

      The company is an equal opportunity employer and will consider all applications without regards to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

Keywords: Actalent, Nashville , Remote Utilization Management Nurse Reviewer, Healthcare , Nashville, Tennessee

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