Utilization Management Registered Nurse (RN) Prior Authorization

Location: Fully remote. Candidates must be available to work Pacific Time hours, Monday through Friday, from 8:00 a.m. to 5:00 p.m.

Description:
Join a fast-growing, dynamic team that is redefining how Utilization Management supports value-based care.

This clinically driven Utilization Management model focuses on ensuring members receive the right care, from the right provider, at the right time. As part of a high-impact transformation initiative, you will strengthen clinical decision-making, improve referral appropriateness, and support better outcomes for members and provider partners.

We are seeking an experienced Managed Care Registered Nurse with exceptional clinical judgment, extensive Prior Authorization experience, and a passion for improving healthcare delivery. This is an opportunity to help shape the future of Utilization Management while working alongside physician leaders and cross-functional teams committed to transforming care.

What You Will Do:

• Perform prospective and retrospective utilization reviews for inpatient, outpatient, and specialty services using evidence-based clinical criteria and nationally recognized guidelines, including MCG.
• Review prior authorization requests to determine medical necessity and clinical appropriateness, ensuring services are delivered at the appropriate level of care and by the appropriate provider.
• Evaluate referrals within high-impact specialty areas, including:Advanced Imaging, Hematology/Oncology, Orthopedic Surgery, Home Health, and Specialty Services
• Apply strong clinical judgment to identify opportunities for members to receive appropriate care within the primary care setting when clinically appropriate.
• Collaborate closely with Medical Directors on complex cases requiring physician review and medical necessity determinations.
• Partner with physicians, care management teams, network management, quality improvement, and practice operations to support coordinated, patient-centered care.
• Interface with health plans, providers, vendors, and regulatory agencies throughout the utilization management process.
• Ensure compliance with CMS, NCQA, DMHC, health plan requirements, organizational policies, and evidence-based clinical guidelines.
• Maintain accurate documentation within Epic Tapestry and other clinical systems, including ICD-10, CPT, and HCPCS coding, as appropriate.
• Participate in annual inter-rater reliability reviews and demonstrate consistent application of clinical guidelines.
• Contribute to process improvement initiatives designed to strengthen Utilization Management, improve referral quality, and support value-based care outcomes.

You Will Be Successful If:

• You demonstrate exceptional clinical judgment and confidence when reviewing complex prior authorization requests.
• You understand that Utilization Management extends beyond approving or denying services and focuses on delivering the most appropriate care for each member.
• You possess extensive knowledge of managed care operations, Medicare Advantage, and evidence-based utilization review.
• You effectively collaborate with physicians and interdisciplinary teams while maintaining strong provider relationships.
• You thrive in a fast-paced, evolving environment focused on continuous improvement and operational excellence.
• You are comfortable working independently, managing competing priorities, and maintaining high-quality clinical decision-making.
• You embrace change and enjoy helping build new care-delivery models that improve outcomes for members and providers.

What You Will Bring:

• An active, unrestricted Registered Nurse license.
• A minimum of five years of Utilization Management experience within a Medicare Advantage health plan, Independent Practice Association, Management Services Organization, delegated medical group, or managed care organization.
• Extensive Prior Authorization experience across inpatient and outpatient services.
• Demonstrated expertise applying MCG Care Guidelines in complex utilization management reviews.
• Strong knowledge of Medicare Advantage regulations, CMS requirements, and medical necessity review.
• Experience reviewing referrals involving one or more of the following: Advanced Imaging, Hematology/Oncology, Orthopedic Surgery, Home Health, and Specialty Referrals
• Experience collaborating with Medical Directors and supporting physician review processes.
• Strong knowledge of ICD-10, CPT, and HCPCS coding.
• Excellent written and verbal communication skills.
• The ability to work independently in a fully remote environment while maintaining productivity and quality standards.

Preferred Qualifications

• Experience with Epic Tapestry.
• Previous experience within a delegated managed care model or Management Services Organization.
• Familiarity with InterQual criteria.
• Experience participating in Utilization Management transformation or process improvement initiatives.
• Lean, Six Sigma, or workflow optimization experience.

About Impresiv Health:

Impresiv Health is a healthcare consulting partner specializing in clinical and operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions that solve their most complex business challenges.

Our approach is, and has always been, simple. First, think and act like the customers who need us. Most importantly, deliver what larger organizations cannot: tangible results that add immediate value at a rate that cannot be beaten. Your success matters, and we know it.

That s Impresiv!