RN Utilization Management Reviewer

Job Summary

A company is looking for a Utilization Management (UM) Nurse Reviewer to integrate clinical expertise into AI-powered prior authorization workflows.

Key Responsibilities

• Apply clinical judgment to ensure outputs align with payer requirements and evidence-based guidelines
• Monitor payer updates and collaborate with product and engineering teams to enhance AI workflows
• Provide feedback to improve knowledge base structure and clinical decision support

Required Qualifications

• Registered Nurse (RN) with an active license
• 5+ years of experience in utilization management or prior authorization
• Broad exposure across multiple specialties such as radiology and oncology
• Strong understanding of payer policies and medical necessity criteria
• Working knowledge of ICD-10, CPT, and HCPCS coding