Utilization Management- RN

Career Opportunities with South Country Health Alliance

We are seeking a Utilization Management RN to join our team. The RN Utilization Management nurse is part of the UM team and conducts medical necessity reviews for pre‑service, post‑service, and other assigned utilization reviews according to product requirements, service type, and organizational workflow.

The role reviews clinical information, applies medical necessity criteria, and ensures coverage determinations are completed accurately and within regulatory and organizational time frames. The RN works with providers, medical directors, internal departments, and other stakeholders to support timely, member‑centered care. A rotating on‑call schedule is required during weekends and holidays.

• Accurately perform pre‑service, concurrent, and post‑service clinical reviews using established medical necessity criteria and guidelines.
• Collaborate with members, clinic/hospital staff, and providers to obtain additional clinical information as needed.
• Maintain assigned workload and meet regulatory and departmental timelines.
• Identify opportunities for quality improvement in the UM program and participate in continuous improvement efforts.
• Apply knowledge of the organization’s products, benefits, provider network, and contracts to minimize out‑of‑network migration.
• Collaborate with claims, provider contact center, provider relations, and contracting on ad‑hoc provider education activities and committees.
• Perform other duties as assigned.

• Current, valid, and unrestricted Minnesota RN license.
• Minimum of 3 years’ clinical experience in a health care setting.
• Experience with Microsoft Office Suite.
• Strong written and verbal communication skills; ability to multitask and prioritize.

• Previous utilization management experience.
• Experience interpreting managed‑care benefit plans and strong knowledge of Medicare and Medicaid.
• Experience applying clinical review criteria such as State/Federal guidelines, Inter Qual, or internal health‑plan policies.
• Telephonic communication and provider follow‑up experience.

• Interpret clinical records and apply critical thinking to make clinical recommendations.
• Strong clinical decision‑making, written and verbal communication with providers and internal teams.
• Attention to detail and accuracy in electronic clinical documentation.
• Experience with electronic medical records, MS Word, Excel, and Outlook
• Time‑management skills with ability to prioritize and adjust to fluctuating workflows.

• Medical, dental, vision, life insurance, short‑ and long‑term disability, pension (PERA), and more.
• Work‑life flexibility; on‑site expectations for this position.
• Predictable pay growth through a structured step‑based salary system.
• Community impact and employee well‑being focus.

Hourly rate ranges from $34.39 to $47.94, depending on experience, education, and other relevant factors.

This position may require occasional on‑site attendance for UM functions and department meetings, but remote work may be possible.

Applicants must be legally authorized to work in the U.S. No sponsorship available.

South Country Health Alliance is an equal‑opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, or protected veteran status.