Utilization Management Nurse (Remote Eligible – Local Residency Required)

Join our dynamic Care Management team as a Utilization Management Nurse, where you'll play a critical role in ensuring appropriate patient care, optimizing hospital resources, and driving strategic outcomes in length of stay and readmission reduction.

What You’ll Do

• Conduct daily Utilization Reviews using MCG criteria to assess medical necessity and patient classification.
• Collaborate with payers to secure ongoing authorization for inpatient stays.
• Resolve order/classification discrepancies and escalate complex cases to the Care Management Physician Advisor.
• Participate in multidisciplinary rounds and strategic initiatives to reduce readmissions and length of stay.
• Educate providers and patients on documentation, classification, and financial implications.
• Prepare persuasive appeals for denied claims and present case studies to leadership.
• Maintain compliance with CMS, Joint Commission, Medicaid, Medicare, and Oregon Nurse Practice Act regulations.

What You Bring

• Minimum 1 year of Utilization Review or Utilization Management experience (MCG required).
• Proficiency in Epic and strong clinical judgment.
• OR RN license submitted and received (preferred: license in hand).
• Ability to hit the ground running in a fast-paced, collaborative environment.
• Excellent communication and negotiation skills with payers and providers.

Work Environment

• Remote work possible after successful orientation, but must reside locally.
• Heavy use of computers and telecommunication tools.
• Pager availability required during day/evening shifts, 7 days/week.