Utilization Management Registered Nurse

About the role

The Utilization Management Registered Nurse applies clinical nursing expertise to interpret, coordinate, document, and communicate medical service and benefit determinations. You will join the One Home/Home Solutions Utilization Management team, which oversees post‑acute care services such as Skilled Nursing Facility (SNF), Home Health, and Durable Medical Equipment (DME), ensuring members receive appropriate care in the right setting.

Key responsibilities

• Interpret clinical information and support coordination, documentation, and communication of medical services and benefit decisions.
• Apply established medical criteria (e.g., Milliman Care Guidelines, Interqual) to make utilization determinations based on physician and provider input.
• Complete request reviews within defined processing time frames (approximately 10 reviews per day).
• Communicate with providers, members, and other stakeholders to facilitate timely care and treatment.
• Contribute to coordinated care delivery and align activities with departmental and organizational goals.

Required profile

• Compact Registered Nurse (RN) license in the state of residence.
• At least one year of clinical experience as an RN in a hospital, SNF, Home Health, or acute‑care setting.
• Passion for improving consumer experiences in health care.

Required skills

• Knowledge of Milliman Care Guidelines or Interqual medical necessity criteria.
• Experience in utilization management or utilization review.
• Familiarity with MDS coordination and discharge planning processes.
• Call‑center or triage experience.
• BSN or equivalent bachelor's degree in a related field.

What we offer

• Work‑at‑home flexibility with required internet specifications.
• Company‑provided telephone equipment.
• Bi‑weekly internet stipend for eligible states.