Utilization Management Registered Nurse

About the role

The Utilization Management RN works within National Medicaid Clinical Operations to review prior‑authorization requests for inpatient services. The nurse ensures each request meets medical necessity criteria, complies with health‑plan policies, and adheres to state and federal regulations while supporting timely, appropriate care for members.

Key responsibilities

• Conduct comprehensive clinical reviews of prior‑authorization requests using evidence‑based guidelines.
• Communicate with providers to obtain missing clinical information and clarify requests.
• Coordinate with medical directors, interdisciplinary teams, and internal departments to support decision‑making.
• Document review findings and decisions in clinical documentation systems promptly.
• Support reporting initiatives and contribute data for performance‑improvement projects.
• Implement quality‑assurance measures, conduct audits, and identify process‑improvement opportunities.
• Educate providers and staff on prior‑authorization policies and criteria, and mentor non‑clinical staff.

Required profile

• Licensed Registered Nurse in Illinois (or willing to obtain licensure upon hire) with no disciplinary actions.
• Minimum 3 years of clinical nursing experience.
• Experience with Medicaid policies and utilization management.
• Proficiency with healthcare software and electronic medical records (EMR) systems.
• Ability to work autonomously and make independent clinical decisions.

Required skills

• Microsoft Word
• Microsoft Outlook
• Microsoft Excel
• Electronic Medical Records (EMR) systems