Utilization Management - Clinical Nurse - Work from Home

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Broad Path is seeking a highly motivated and results-oriented UM Clinical Nurse to join our team. As the UM Clinical Nurse, you will be responsible for precertification of inpatient hospitalizations and outpatient procedures requiring authorization. Conducts telephonic and concurrent review of hospitalizations and extended outpatient treatments, applying clinical judgment, utilization management principles, and medical necessity criteria while ensuring regulatory compliance.

Responsibilities

• Analyze clinical information, treatment plans, and regulatory guidelines for authorization requests
• Apply clinical decision-making to assess acuity and treatment appropriateness
• Create case summaries for requests not meeting medical necessity criteria and collaborate with medical directors
• Research clinical guidelines and stay current on Medicaid manual changes
• Evaluate discharge planning risks and facilitate appropriate continuity of care
• Meet regulatory timelines for assessments, decisions, and communications
• Ensure timely processing of all denial determinations according to regulations
• Document due process and attempt to gather adequate clinical information
• Notify providers of denials, offering peer-to-peer conversations and communicating appeal processes
• Distributed denial letters to all involved parties within regulatory time frames
• Hold discussions with providers regarding guideline application and coverage determinations
• Document all provider interactions in the authorization system
• Promote provider satisfaction through education on managed care and authorization requirements
• Serve as liaison between providers and facilities to promote quality service and care
• Screen and identify potential members for case management programs
• Recommend care planning based on projected treatment course and prognosis
• Coordinate with hospital staff on discharge service packages to reduce readmission risk
• Prepare cost-benefit analyses for exceptional coverage situations
• Identify potential quality issues, fraud, or abuse concerns
• Coordinate with UM Analyst staff on appeals and complaints
• Ensure compliance with regulatory standards and contractual requirements
• Participate in quarterly inter-rater reliability reviews

Qualifications

• RN license in an eNLC (Enhanced Nurse Licensure Compact) state with multistate privileges
• 3+ years Nursing experience
• 1+ years Utilization Management experience
• Familiarity with medical terminology, utilization management guidelines, and clinical documentation standards
• Proficiency in Microsoft Office and experience working with healthcare systems or electronic medical records
• Strong organizational and time management skills with the ability to work independently
• Excellent written and verbal communication skills

Preferred Qualifications

• Experience in managed care
• Experience in pediatrics

Diversity Statement

At Broad Path, diversity is our strength. We embrace individuals from all backgrounds, experiences, and perspectives. We foster an inclusive environment where everyone feels valued and empowered. Join us and be part of a team that celebrates diversity and drives innovation!

Equal Employment Opportunity/Disability/Veterans

If you need accommodation due to a disability, please email us at  This information will be held in confidence and used only to determine an appropriate accommodation for the application process.

Broad Path is an Equal Opportunity Employer

We do not discriminate against our applicants because of race, color, religion, sex (including gender identity, sexual orientation, and pregnancy), national origin, age, disability, veteran status, genetic information, or any other status protected by applicable law.

• Seniority level Associate

• Employment type
  
  Full-time

• Job function
  
  Customer Service
• Industries Outsourcing and Offshoring…