Remote Utilization Management RN

Company Description Liberty Medicare Advantage Plan is a health plan dedicated to providing high-quality, patient-centered care to Medicare beneficiaries. The organization focuses on improving health outcomes through coordinated care, evidence-based practices, and comprehensive member support services. Team members collaborate across disciplines to ensure members receive appropriate, timely, and cost-effective care. The plan values integrity, clinical excellence, and innovation in managing utilization and enhancing the member experience.
Role Description The Remote Utilization Management RN is a full-time role responsible for reviewing medical necessity and appropriateness of services for Medicare Advantage members. On a day-to-day basis, this role conducts prospective, concurrent, and retrospective utilization reviews using established clinical guidelines and regulatory requirements. The RN collaborates with providers, case managers, and internal teams to coordinate care, authorize services, and identify opportunities for alternative, cost-effective treatment options. The position involves documenting clinical decisions, preparing determinations, participating in appeals processes, and supporting quality improvement initiatives. This is a remote role requiring effective time management, secure handling of member information, and consistent adherence to organizational policies and CMS regulations.
Qualifications
Active, unrestricted Registered Nurse (RN) license in good standing, with compact licensure preferred.
Several years of clinical experience in acute care, case management, or utilization management within managed care or Medicare Advantage settings.
Demonstrated knowledge of utilization management principles, medical necessity criteria (e.g., InterQual, MCG), and CMS/Medicare regulations.
Strong assessment, critical thinking, and clinical decision-making skills for evaluating medical records and treatment plans.
Proficiency with electronic health records, care management platforms, and standard office software (e.g., MS Office, secure communication tools).
Excellent written and verbal communication skills, with the ability to explain clinical determinations clearly to providers and internal stakeholders.
Ability to work independently in a remote environment, manage competing priorities, and meet performance and turnaround-time standards.
Experience participating in interdisciplinary teams, coordinating care, and supporting quality and compliance initiatives.
Familiarity with prior authorization processes, appeals, grievances, and documentation requirements in a health plan environment.
Associate or Bachelor of Science in Nursing (ASN/BSN) preferred; relevant certifications in case management or utilization review (e.g., CCM, CPUR) are a plus.
For qualified experienced UM RNs please apply at Liberty Medicare Advantage.com

Work arrangement
Yes