About the position A Managed Care Organization is seeking a Utilization Management Nurse to review provider-submitted service authorization requests and evaluate medical necessity, with a primary focus on behavioral health services. This position plays a key role in ensuring members receive appropriate and timely care by performing prior authorizations and concurrent reviews.

Responsibilities

• Review provider submissions for prior service authorizations, particularly in behavioral health
• Evaluate requests for medical necessity and appropriate service levels
• Provide concurrent review and prior authorization according to internal policies
• Identify appropriate benefits and determine eligibility and expected length of stay
• Collaborate with internal departments, including Behavioral Health and Long Term Care, to ensure continuity of care
• Refer cases to medical directors as needed
• Maintain productivity and quality standards
• Participate in staff meetings and assist with onboarding of new team members
• Foster professional relationships with internal teams and provider partners

Requirements

• Background in Behavioral Health services and/or experience with a Managed Care Organization (MCO) in Utilization Management
• Active, unrestricted RN, LPN, LCSW, or LPC license
• Completion of an accredited Registered Nursing program (or equivalent combination of experience and education)
• 2 years of clinical experience, preferably in hospital nursing, utilization management, or case management
• Understanding of state and federal healthcare regulations
• Experience with InterQual and NCQA standards
• Strong organizational, communication, and problem-solving skills
• Proficient in Microsoft Office and electronic documentation systems
• Ability to work independently and manage multiple priorities
• Professional demeanor and commitment to confidentiality and compliance with HIPAA standards
• Team-oriented with the ability to build and maintain positive working relationships