Clinical Utilization Management Nurse Specialist (USRN)

Clinical Utilization Management Nurse Specialist (USRN)

• Work Arrangement: Onsite (TP Vertis North)
• Schedule: US Day Shift

Use your clinical expertise to review prior authorization and or concurrent review requests against clinical guidelines and ensure members receive appropriate, timely, and cost‑effective care within a US managed care environment.

What You'll Do

• Review prior authorization and or concurrent requests for medical necessity and level of care.
• Coordinate with providers and internal teams for timely case resolution.
• Escalate cases requiring higher‑level review to Medical Directors.
• Support discharge planning and transfer authorization workflows (for concurrent)
• Document clinical information accurately and in compliance with standards.
• Provide utilization process guidance to providers and internal teams.

What You Need

• Graduate of an accredited School of Nursing; BSN
• Active USRN license (NCLEX‑passed), non-restricted
• 1-year clinical experience (hospital, clinic, or academe) plus 1 year in UM (Prior Authorization, or Concurrent Review – preferred); or 2 years in UM, Prior Authorization, or Concurrent Review - preferred
• Knowledge of Medicare/Medicaid and managed care fundamentals.
• Strong analytical, documentation, and communication skills.
• Amenable to US shift and onsite/hybrid setup.

Preferred

• Healthcare BPO or payer experience.
• Familiarity with InterQual, MCG, or similar criteria tools.