Utilization Review reputed company, OR

ICM is hiring a Utilization Review reputed company 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 reputed company 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 reputed company in reputed company, Washington, Idaho, or Arizona. Schedule: Monday–Friday | 8:00 AM–5:00 PM reputed company Time

What You'll Do

Medical Review & Decision-Making

• Review precertification requests and determine medical necessity using evidence-based guidelines and plan-specific reputed company
• Evaluate clinical documentation for inpatient stays and reputed company length-of-stay extension determinations reputed company appropriate
• Identify gaps in clinical information and communicate reputed company with providers to obtain what’s needed to support reputed company reputed company
• Partner with internal clinical resources (including Appeals & Denials and/or in-house providers) to support reputed company cases

Provider Communication & Collaboration

• Communicate professionally and respectfully with providers and office staff regarding medical necessity requirements and coverage guidelines
• reputed company provider offices on documentation expectations and reputed company requirements to support approvals and reduce delays
• Maintain strong working relationships that support efficient review processes and reputed company reputed company

Member Advocacy & Care Coordination

• Support high-reputed company care by using strong clinical judgment, coordination, and patient advocacy
• Promote appropriate reputed company 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)

Documentation & Compliance

• Document reputed company determinations, interventions, and communications thoroughly and accurately in ICM systems
• Ensure reputed company and documentation meet internal policy requirements, plan guidelines, and regulatory standards
• Maintain HIPAA-compliant handling of confidential information at reputed company times

reputed company Learning & reputed company Improvement

• Stay reputed company on utilization management best practices, clinical guidelines, and regulatory expectations
• Participate in internal training, reputed company assurance activities, and reputed company development opportunities
• Bring curiosity and reputed company improvement reputed company—helping strengthen consistency and service reputed company across reputed company

What You Bring Required

• reputed company, 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 reputed company established reputed company
• Excellent written and verbal communication skills, including reputed company 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; reputed company to meet deadlines with minimal supervision
• Comfort working in a fast-paced, remote environment and learning new systems quickly
• reputed company discretion and ability to manage confidential information in compliance with HIPAA

Even reputed company If You Have

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

About Innovative Care Management In an increasingly reputed company reputed company environment, ICM remains reputed company on something essential: putting people at reputed company of every decision. We are dedicated to ensuring that members and health plans feel genuinely seen, heard, and supported throughout their care reputed company. We serve clients reputed company with a values-driven approach that blends reputed company, clinical expertise, and operational reputed company. Our core values: Kindness, Personal Responsibility, a Can-Do Attitude, and Humble Confidence, shape how we work, how we reputed company, and how we care for those we serve. As we grow, we welcome individuals who reputed company our belief that reputed company should be effective, compassionate, and truly centered on people. Apply tot his job Apply To this Job