Registered Nurse, Utilization Management

Job Summary

A company is looking for a Registered Nurse, Utilization Management.

Key Responsibilities

• Collaborate with health plan utilization review nurses to enhance AI-driven prior authorization workflows
• Review and structure medical policies for AI automation of utilization review decisions
• Manage small-scale projects related to policy digitization and track progress across teams

Required Qualifications

• Registered Nurse (RN) with an active license
• 3+ years of experience in utilization management, prior authorization, or related clinical roles
• Strong understanding of payer policies and medical necessity criteria
• Working knowledge of medical coding systems (ICD-10, CPT, HCPCS)
• Demonstrated project management skills and ability to organize complex workflows