Utilization Management RN

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, aligns with health‑plan policies, and complies with 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 healthcare 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 accurately in clinical documentation systems.
• Implement quality‑assurance measures, perform audits, and identify process‑improvement opportunities.
• Educate providers and staff on prior‑authorization policies and criteria.

Required profile

• Licensed Registered Nurse in Illinois (or willing to obtain licensure upon hire).
• Minimum 3 years of clinical nursing experience.
• Experience with Medicaid policies and utilization management processes.
• Ability to work autonomously and make independent clinical decisions.

Required skills

• Proficiency with electronic medical record (EMR) systems and healthcare software.
• Strong knowledge of Microsoft Word, Outlook, and Excel.