Utilization Management Registered Nurse (RN) Prior Authorization

Location: Fully remote. Candidates must be available to work Pacific Time hours, Monday through Friday, from 8:00 a.m. to 5:00 p.m.

Description:
Join a fast-growing, dynamic team that is redefining how Utilization Management supports value-based care.

This clinically driven Utilization Management model focuses on ensuring members receive the right care, from the right provider, at the right time. As part of a high-impact transformation initiative, you will strengthen clinical decision-making, improve referral appropriateness, and support better outcomes for members and provider partners.

We are seeking an experienced Managed Care Registered Nurse with exceptional clinical judgment, extensive Prior Authorization experience, and a passion for improving healthcare delivery. This is an opportunity to help shape the future of Utilization Management while working alongside physician leaders and cross-functional teams committed to transforming care.

What You Will Do:

• Perform prospective and retrospective utilization reviews for inpatient, outpatient, and specialty services using evidence-based clinical criteria and nationally recognized guidelines, including MCG.
• Review prior authorization requests to determine medical necessity and clinical appropriateness, ensuring services are delivered at the appropriate level of care and by the appropriate provider.
• Evaluate referrals within high-impact specialty areas, including:
  Advanced Imaging , Hematology/Oncology, Orthopedic Surgery, Home Health, and Specialty Services
• Apply strong clinical judgment to identify opportunities for members to receive appropriate care within the primary care setting when clinically appropriate.
• Collaborate closely with Medical Directors on complex cases requiring physician review and medical necessity determinations.
• Partner with physicians, care management teams, network management, quality improvement, and practice operations to support coordinated, patient-centered care.
• Interface with health plans, providers, vendors, and regulatory agencies throughout the utilization management process.
• Ensure compliance with CMS, NCQA, DMHC, health plan requirements, organizational policies, and evidence-based clinical guidelines.
• Maintain accurate documentation within Epic Tapestry and other clinical systems, including ICD-10, CPT, and HCPCS coding, as appropriate.
• Participate in annual inter-rater reliability reviews and demonstrate consistent application of clinical guidelines.
• Contribute to process improvement initiatives designed to strengthen Utilization Management, improve referral quality, and support value-based care outcomes.

You Will Be Successful If:

• You demonstrate exceptional clinical judgment and confidence when reviewing complex prior authorization requests.
• You understand that Utilization Management extends beyond approving or denying services and focuses on delivering the most appropriate care for each member.
• You possess extensive knowledge of managed care operations, Medicare Advantage, and evidence-based utilization review.
• You effectively collaborate with physicians and interdisciplinary teams while maintaining strong provider relationships.
• You thrive in a fast-paced, evolving environment focused on continuous improvement and operational excellence.
• You are comfortable working independently, managing competing priorities, and maintaining high-quality clinical decision-making.
• You embrace change and enjoy helping build new care-delivery models that improve outcomes for members and providers.

What You Will Bring:

• An active, unrestricted Registered Nurse license.
• A minimum of five years of Utilization Management experience within a Medicare Advantage health plan, Independent Practice Association, Management Services Organization, delegated medical group, or managed care organization.
• Extensive Prior Authorization experience across inpatient and outpatient services.
• Demonstrated expertise applying MCG Care Guidelines in complex utilization management reviews.
• Strong knowledge of Medicare Advantage regulations, CMS requirements, and medical necessity review.
• Experience reviewing referrals involving one or more of the following:
  Advanced Imaging, Hematology/Oncology, Orthopedic Surgery, Home Health, and Specialty Referrals
• Experience collaborating with Medical Directors and supporting physician review processes.
• Strong knowledge of ICD-10, CPT, and HCPCS coding.
• Excellent written and verbal communication skills.
• The ability to work independently in a fully remote environment while maintaining productivity and quality standards.

Preferred Qualifications

• Experience with Epic Tapestry.
• Previous experience within a delegated managed care model or Management Services Organization.
• Familiarity with Inter Qual criteria.
• Experience participating in Utilization Management transformation or process improvement initiatives.
• Lean, Six Sigma, or workflow optimization experience.

About Impresiv Health:

Impresiv Health is a healthcare consulting partner specializing in clinical and…