UM RN - Behavioral Health

Accountabilities: The UM RN - Behavioral Health will use clinical expertise to evaluate, coordinate, and manage behavioral health services while ensuring appropriate utilization of healthcare benefits. The role involves collaboration with members, providers, and internal teams to support effective care planning, regulatory compliance, and positive health outcomes.

Perform prospective, concurrent, and retrospective utilization reviews for inpatient, outpatient, ambulatory, and ancillary behavioral health services.

Assess medical necessity, appropriate levels of care, treatment duration, and service intensity using established clinical criteria and guidelines.

Review and process authorization requests, including elective, urgent, emergency, direct, and ancillary service requests.

Collaborate with providers, facilities, and healthcare professionals to identify appropriate treatment options and alternative care solutions.

Develop, coordinate, and communicate discharge planning activities with internal and external stakeholders.

Support care coordination efforts by establishing care plans and facilitating services across the healthcare continuum.

Research and resolve issues related to benefits, eligibility, unauthorized services, coordination of benefits, and member care needs.

Analyze and prepare documentation for retrospective reviews, appeals, and regulatory requirements.

Communicate with members, providers, and other stakeholders to facilitate effective treatment planning.

Provide education to provider communities regarding policies, procedures, benefits, and utilization management practices.

Identify opportunities to improve healthcare quality, service effectiveness, and benefit utilization.

Support additional departmental responsibilities as needed.

Requirements:

The ideal candidate is a licensed registered nurse with behavioral health experience and a strong understanding of utilization management processes. They should demonstrate clinical expertise, regulatory awareness, and the ability to communicate effectively with diverse healthcare stakeholders.

Current unrestricted Registered Nurse (RN) license required.

Minimum of 2 years of acute clinical nursing experience.

At least 1 year of behavioral health clinical experience.

Experience in managed care, utilization management, or health insurance environments preferred.

Case Management certification or progress toward certification is highly preferred.

Strong knowledge of medical necessity criteria, clinical guidelines, and healthcare service levels.

Understanding of current nursing practices, behavioral health trends, alternative care settings, and treatment approaches.

Knowledge of healthcare policies, procedures, member benefits, community resources, and applicable regulations.

Familiarity with accreditation standards such as NCQA and healthcare compliance requirements.

Excellent written and verbal communication skills.

Strong interpersonal, problem-solving, and customer service abilities.

Proficiency with Microsoft Office applications and remote communication technologies.

Ability to work effectively across multiple time zones in a remote environment.

Benefits:

Competitive annual salary range of $65,000 - $85,000 , depending on skills, experience, qualifications, and education.

Full-time, permanent remote position.

Opportunity to apply clinical expertise while improving healthcare access and outcomes.

Supportive environment focused on professional growth and continuous learning.

Potential opportunities for certification advancement and career development.

Collaborative work with healthcare professionals across multiple disciplines.

Employee benefits package designed to support overall well-being.

How Jobgether works: We use an AI-powered matching process to ensure your application is reviewed quickly, objectively, and fairly against the role's core requirements. Our system identifies the top-fitting candidates, and this shortlist is then shared directly with the hiring company. The final decision and next steps (interviews, assessments) are managed by their internal team. We appreciate your interest and wish you the best!  Why Apply Through Jobgether? 

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