Utilization Management RN

Job Summary

A company is looking for a Utilization Management RN - Payer Operations.

Key Responsibilities

• Partner with health plan utilization review nurses to validate and improve AI-driven prior authorization workflows
• Review and structure medical policies to enable AI-powered automation of utilization review decisions
• Manage small-scale projects, including organizing digitization initiatives and tracking timelines

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 the prior authorization process
• Working knowledge of medical coding systems (ICD-10, CPT, HCPCS)
• Demonstrated project management skills and ability to manage complex workflows