Utilization Review Nurse, OR

ICM is hiring a Utilization Review Nurse 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 aligned 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 reside in Oregon, Washington, Idaho, or Arizona. Schedule: Monday–Friday | 8:00 AM–5:00 PM Pacific Time

What You'll Do

Medical Review & Decision-Making

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

Provider Communication & Collaboration

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

Member Advocacy & Care Coordination

• Support high-quality care by using strong clinical judgment, coordination, and patient advocacy
• Promote appropriate levels 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 all determinations, interventions, and communications thoroughly and accurately in ICM systems
• Ensure decisions and documentation meet internal policy requirements, plan guidelines, and regulatory standards
• Maintain HIPAA-compliant handling of confidential information at all times

Continuous Learning & Quality Improvement

• Stay current on utilization management best practices, clinical guidelines, and regulatory expectations
• Participate in internal training, quality assurance activities, and professional development opportunities
• Bring curiosity and continuous improvement mindset—helping strengthen consistency and service excellence across the team

What You Bring Required

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

Even Better If You Have

• Experience in a Third Party Administrator (TPA) or self-funded health plan environment
• Knowledge of health insurance regulations and utilization management processes
• Experience using medical necessity criteria (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 complex healthcare environment, ICM remains focused on something essential: putting people at the center of every decision. We are dedicated to ensuring that members and health plans feel genuinely seen, heard, and supported throughout their care journey. We serve clients nationwide with a values-driven approach that blends compassion, clinical expertise, and operational excellence. Our core values: Kindness, Personal Responsibility, a Can-Do Attitude, and Humble Confidence, shape how we work, how we lead, and how we care for those we serve. As we grow, we welcome individuals who share our belief that healthcare should be effective, compassionate, and truly centered on people. Apply To This Job