Utilization Review Nurse – RN or LVN - Full Remote

Utilization Review Nurse – RN or LVN (Remote, $43/hr) Join one of the nation’s leading managed care organizations, committed to transforming health care for underserved communities. Our client is a mission-driven health plan known for delivering accessible, high-quality care to millions of members. With a reputation for innovation and collaboration, they’re looking for compassionate, skilled clinicians to help ensure members receive the right care at the right time — every time. We are seeking experienced Registered Nurses (RNs) or Licensed Vocational/Practical Nurses (LVNs/LPNs) with prior authorization and/or behavioral health utilization management experience to join a dedicated Utilization Management (UM) team. This is a fully remote, full-time opportunity starting in September 2025. Position Details

• Pay Rate: $43.00 per hour
• Schedule: Monday to Friday, 8:00 AM – 5:00 PM (1-hour lunch)
• Work Location: 100% remote
• Licensure: Must hold an active, unrestricted RN or LVN license in Ohio or a compact state. Preference for Ohio residents and licenses. Position Summary The Utilization Review Nurse is responsible for inpatient and outpatient medical necessity review, prior authorizations, and other UM activities. The goal is to ensure members receive appropriate, bolthires-effective, and timely care while supporting compliance with regulatory standards and promoting positive health outcomes.

Key Responsibilities

• Perform concurrent review and prior authorization assessments per company policy
• Evaluate member eligibility, benefits, and appropriate level of care
• Participate in interdepartmental collaboration (Behavioral Health, Long-Term Care, etc.)
• Document and maintain productivity and quality standards
• Assist in onboarding and mentoring new team members
• Consult regularly with medical directors and escalate as needed
• Represent the organization professionally with internal and external stakeholders
• Adhere to HIPAA, safety, and ethical standards in daily operations Required Qualifications
• Education: Completion of an accredited Registered Nursing or Vocational Nursing program (comparable experience/education combinations may be considered)
• Experience:
• Minimum 2 years UM or case management in a managed care organization
• Experience with prior authorizations and/or behavioral health outpatient services
• Licensure: Active, unrestricted RN or LVN license in Ohio or a compact state. Preference to Ohio residents and licenses.
• Technical Skills:
• Familiarity with InterQual criteria and UM software
• bolthires Office proficiency (Word, Excel, Outlook)
• Additional Skills:
• Strong communication, organization, and multitasking
• Knowledge of NCQA and regulatory standards
• Ability to work independently and meet deadlines in a fast-paced environment