Utilization Review Nurse – Outpatient (Remote)

We are seeking an experienced Utilization Review Nurse (Outpatient) to join our remote Utilization Management team. This role focuses on reviewing medical necessity for outpatient services, including DME, therapy, surgery, and imaging. The ideal candidate has experience with Virginia Medicaid (preferred) or other state Medicaid programs and is highly organized, self-motivated, and comfortable working independently to meet productivity and turnaround time (TAT) requirements. You will assess services for members to ensure appropriate care, optimal outcomes, cost effectiveness, and compliance with state and federal guidelines.

Perform medical necessity reviews for outpatient services such as DME, physical/occupational therapy, surgical procedures, imaging, and other related requests Self-pull cases from queue and process efficiently while meeting turnaround time and quality expectations Apply evidence-based criteria (e.g., InterQual, MCG, CMS LCD/NCD) to determine authorization outcomes Collaborate with Medical Directors for secondary reviews when needed Identify eligibility, benefits, and expected length of stay for outpatient services Ensure timely and appropriate documentation of all clinical decisions Support discharge planning and coordinate with internal teams for transition of care when applicable Maintain compliance with Virginia Medicaid or other state Medicaid guidelines and policies Work independently in a structured remote environment using Microsoft Teams, Excel, Outlook, and clinical systems Participate in regular team meetings, audits, and staff development initiatives Demonstrate a professional, approachable, and collaborative demeanor