Utilization Review Nurse

Innovative Care Management, Inc.

9d•Remote

About The Position

ICM is hiring a Utilization Review Nurse to support our Utilization Review team by evaluating medical necessity requests and reviewing ongoing hospital stays to ensure services are clinically appropriate, cost-effective, and aligned with plan guidelines. This role plays a key part in ensuring members receive the right care at the right time, while supporting regulatory compliance, excellent documentation practices, and strong collaboration with providers and internal clinical teams. This is a fully remote role. Candidates must reside in Oregon, Washington, Idaho, or Arizona. Schedule: Monday–Friday | 8:00 AM–5:00 PM Pacific Time

Requirements

Active, unrestricted LPN or RN license in good standing
Associate’s or Bachelor’s degree in Nursing
3+ years of clinical nursing experience in acute care, managed care, and/or utilization review
Strong medical necessity decision-making skills and comfort working within established criteria
Excellent written and verbal communication skills, including empathy and professionalism in provider/member interactions
Strong organization, attention to detail, and ability to manage multiple priorities independently
High level of accountability and follow-through; able to meet deadlines with minimal supervision
Comfort working in a fast-paced, remote environment and learning new systems quickly
Professional discretion and ability to manage confidential information in compliance with HIPAA

Nice To Haves

Experience in a Third Party Administrator (TPA) or self-funded health plan environment
Knowledge of health insurance regulations and utilization management processes
Experience using medical necessity criteria (e.g., InterQual, MCG, or similar)
Experience with EMRs and utilization review platforms
Utilization/case management certifications such as CCM, CPUR, or CPHM

Responsibilities

Review precertification requests and determine medical necessity using evidence-based guidelines and plan-specific criteria
Evaluate clinical documentation for inpatient stays and make length-of-stay extension determinations when appropriate
Identify gaps in clinical information and communicate clearly with providers to obtain what’s needed to support timely decisions
Partner with internal clinical resources (including Appeals & Denials and/or in-house providers) to support complex cases
Communicate professionally and respectfully with providers and office staff regarding medical necessity requirements and coverage guidelines
Educate provider offices on documentation expectations and criteria requirements to support approvals and reduce delays
Maintain strong working relationships that support efficient review processes and positive outcomes
Support high-quality care by using strong clinical judgment, coordination, and patient advocacy
Promote appropriate levels of care and continuity of treatment
Support efficient discharge planning and reduce unnecessary utilization
Identify cases that would benefit from additional clinical support and refer to: Case Management Disease Management Healthy Mother Baby program (as applicable)
Document all determinations, interventions, and communications thoroughly and accurately in ICM systems
Ensure decisions and documentation meet internal policy requirements, plan guidelines, and regulatory standards
Maintain HIPAA-compliant handling of confidential information at all times
Stay current on utilization management best practices, clinical guidelines, and regulatory expectations
Participate in internal training, quality assurance activities, and professional development opportunities
Bring curiosity and continuous improvement mindset—helping strengthen consistency and service excellence across the team