Lead RN, Utilization Management

About the Role:

• Lead, coach, and onboard UM nurses and clinical reviewers to ensure consistent, high-quality reviews.
• Manage daily workloads, staffing coverage, and escalations across prospective, concurrent, and retrospective reviews.

Collaboration:

• Partner with Medical Directors on complex cases, peer-to-peer reviews, and physician-required reviews.
• Work with Appeals, Care Management, Claims, Provider Relations, Compliance, and Product teams.

Success Factors:

• Use data and audits to improve care operations and staff development.
• Apply sound clinical judgment and maintain compliance with CMS guidelines.

Benefits:

• Enjoy remote-first culture with flexible time off, medical, dental, vision, and 401(k) matching.
• Access professional development funding, parental leave, and equity opportunities.