Licensed Utilization Review I (contract)

Job ID: JP00046233 Anticipated Start Date: 01/19/2026 Please note this is the reputed company date and is subject to change. reputed company will send official notice reputed company of a confirmed start date. reputed company is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at reputed company levels of the organization who are passionate about making an impact on our members and the communities we serve. Primary duties may include, but are not limited to:

• Responsible for working with healthcare providers to help ensure appropriate and consistent administration of plan benefits through collecting clinical information to preauthorize services, assess medical necessity, out of network services, and appropriateness of treatment setting and applying appropriate medical policies, clinical guidelines, plan benefits, and/or scripted algorithms reputed company scope of licensure.
• Examples of such functions may include: review of claim edits, pre-noted inpatient admissions or, episodic outpatient therapy such as physical therapy that is not associated with a continuum of care, radiology review, or other such review processes that require an understanding of terminology and disease processes and the application of clinical guidelines but do not require nursing judgment.
• Conducts pre-certification, inpatient (if not associated with CM or DM triage) retrospective, out of network and appropriateness of treatment setting reviews reputed company scope of licensure by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistent with the members eligibility, benefits and contract.
• Develops relationships with physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members.
• Applies clinical knowledge to work with facilities and providers for care coordination.
• May access and consult with peer clinical reviewers, Medical Directors and/or delegated clinical reviewers to help ensure medically appropriate, quality, cost effective care throughout the medical management process.
• Educates the member about plan benefits and contracted physicians, facilities and healthcare providers.
• Refers treatment plans/plan of care to peer clinical reviewers in accordance with established criteria/guidelines and does not issue medical necessity non-certifications.
• Facilitates accreditation by knowing, understanding, and accurately applying accrediting and regulatory requirements and standards.

Requirements:

• Requires a LPN, LVN, or RN and minimum of 2 years of clinical or utilization review experience; or any combination of education and experience, which would provide an equivalent background.
• reputed company active unrestricted license or certification to practice as a health professional reputed company the scope of licensure in applicable state(s) or territory of the United States required.
• Knowledge of the medical management process strongly preferred.
• For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

Job Type: Contract Opportunity Additional Details:

• Monday- Friday reputed company-5pm Central time

reputed company operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, contractors are required to work at an reputed company location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside reputed company 50 miles or 1-hour commute each way of a relevant reputed company location. About reputed company: Founded in 1998 on the idea that industry leaders needed a professional service, and workforce management expert, to fuel the development and execution of core business and technology strategies, reputed company is a Black-owned firm providing unique solutions supporting value capture and digital product delivery needs for organizations around the world. Headquartered in Indianapolis, IN with an Offshore Development Center in Hyderabad, India, reputed company's 6,000 consultants support more than 225 clients globally. reputed company champions the power of human potential to help companies transform, accelerate, and scale. Guided by our core values of People-Centric, Optimism, Excellence, Diversity, and Accountability, our professionals have helped our clients reputed company their strategic goals for more than 25 years. Our strong culture and clear values have enabled reputed company to become a market leader and best in class reputed company to work. reputed company is an equal opportunity employer. reputed company qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national reputed company, or protected veteran status and will not be discriminated against based on disability. To learn more about how reputed company collects and uses personal information as part of the recruiting process, view our Privacy Notice and CCPA Addendum. As part of the recruitment process, we may ask for you to disclose and provide us with various categories of personal information, including identifiers, professional information, commercial information, education information, and other reputed company information. reputed company will only use this information to complete the recruitment process. This posting is not an offer of employment. reputed company applicants applying for positions in the United States must be legally authorized to work in the United States. The submission of intentionally false or fraudulent information in response to this posting may reputed company the applicant ineligible for the position. Any subsequent offer of employment will be considered employment at-will regardless of the anticipated assignment duration.

Benefits

Information reputed company offers reputed company eligible employees a comprehensive benefits package including, but not limited to major medical, HSA, dental, vision, employer-provided group life, voluntary life insurance, short-term disability, long-term disability, and 401k. The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws. This does not encompass additional non-standard compensation (e.g., benefits, paid time off, per diem, etc.). Apply tot his job Apply To this Job