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We are seeking a clinically experienced Registered Nurse to join our Utilization Management team in a part-time, fully remote capacity. In this role, you'll assess the medical necessity and quality of healthcare services through prospective, concurrent, and retrospective utilization reviews — playing a critical role in ensuring patients receive appropriate, high-quality care. 

What You'll Do

• Apply clinical review criteria, organizational policies, and guidelines (including ASAM and InterQual) to determine medical necessity of healthcare services
• Conduct prospective, concurrent, and retrospective utilization management reviews
• Review and evaluate treatment plans to substantiate clinical appropriateness and support quality patient outcomes
• Screen progress notes and pertinent health records to determine appropriateness for admission; perform initial and continued stay reviews
• Review case files to ensure appropriate level of care on admission and prior to discharge
• Consult with physician and practitioner consultants when reviews fail clinical criteria or guidelines
• Refer cases to other clinicians when indicated
• Document all utilization review decisions accurately in the appropriate database
• Communicate review timelines with clients, internal teams, and providers as appropriate
• Assist with appeal case preparation for medical affairs in accordance with departmental policies
• Report HIPAA or PHI violations promptly into the appropriate organizational database
• Serve as a subject matter resource for peers and care management staff on utilization review processes and questions
• Provide daily oversight and monitoring of non-clinical staff performing support activities, as appropriate, and provide supervisory input on performance
• Support quality assurance audits and other program initiatives as assigned

Please note: This role is Part time 10-20 hours weekly

What We're Looking For

• Current, active, unrestricted RN license in Washington, DC
• Associate's Degree in Nursing or higher
• Minimum 3 years of direct patient care (clinical) experience
• Minimum 1 year of utilization review or other medical management experience
• Strong proficiency in Microsoft Office Suite and familiarity with database software
• Exceptional organizational skills with the ability to manage multiple concurrent tasks
• Excellent written and verbal communication skills
• Strong interpersonal and problem-solving abilities
• Comfortable working independently in a remote environment while collaborating effectively within a team
• High degree of professionalism and strict adherence to HIPAA/PHI standards

Preferred Qualifications

• 2 or more years of utilization review or medical management experience
• Familiarity with ASAM, InterQual, or similar clinical review criteria tools
• Experience in managed care, health plan, or insurance-based clinical settings

For immediate consideration, send your resume to mmercer@nri-staffing.com