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Utilization Review Nurse - Remote

November 11, 2025

Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015. <h2>Position Summary </h2>The Utilization Review Nurse works as a member of a team responsible for ensuring the receipt of high quality, cost efficient medical outcomes for those enrollees with a need for inpatient/ outpatient authorizations. This position receives and reviews prior authorization requests for specific inpatient and outpatient medical services, receives and reviews notification of emergent hospital admissions, completes inpatient concurrent review, establishes discharge plans, coordinates transitions of care to lower/higher levels of care, makes referrals for care management programs, and performs medical necessity reviews for retrospective authorization requests as well as claims disputes. The Utilization Review Nurse will use appropriate governmental policies as well as specified clinical guidelines/ criteria to guide medical necessity reviews and will use effective relationship management, coordination of services, resource management, education, patient advocacy and related interventions to: -Ensure members are receiving appropriate level of care -Promote cost effective medical outcomes -Prevent hospitalization/ readmissions when appropriate -Promote decreased lengths of hospital stays when appropriate -Provide for continuity of care<h2> Job Description</h2>Key Outcomes/Results:<ul><li>Review prior authorization requests (prior authorization, concurrent review, and retrospective review) for medical necessity referring to Medical Director as needed for additional expertise and review.</li><li>Utilize evidenced-based criteria, governmental policies, and internal guidelines for medical necessity reviews.</li><li>Manage the review of medical claims disputes, records, and authorizations for billing, coding, and other compliance or reimbursement related issues</li><li>Collaborates with other members of the team, the MPHC Medical Directors, healthcare providers, and members to promote effective utilization of resources. This collaboration includes timely communications with in and out of network hospitals, post-acute care facilities, other providers, and internal departments to: authorize services, establish discharge plans, assist to coordinate effective, efficient transitions of care.</li><li>Coordinates referrals to Care Management, as appropriate.</li><li>Manages health care within the benefits structures per line of business and performs functions within compliance, contractual and accreditation regulations, e.g. Department of Defense, Centers for Medicaid and Medicare, NCQA, Employer contracts and state insurance regulations, as applicable. Maintains knowledge of applicable regulatory guidelines.</li><li>Completes all documentation of reviews and decisions, in appropriate systems, according to process/ compliance requirements and within timeliness standards.</li><li>Participates as a member of an interdisciplinary team in the Health Management Department</li><li>May be responsible for maintaining a caseload for concurrent cases/ assisting in caseload coverage for the team</li><li>Acts as a liaison to ensure the member is receiving the appropriate level of care at the appropriate place and time</li><li>Mentors new staff into case management role as assigned.</li><li>Assumes extra duties as assigned based on business needs.</li><li>Participates on committees, work groups, team rounds, and/or projects as designated.</li><li>Attends on-going training/continuing education, at a minimum annually, to maintain professional competency.</li><li>Assists in creation and updating of department Policies and Procedures.</li><li>Participates in quality initiatives and process improvements that reinforce best practice medical management programming and offerings.</li></ul>Education/Experience:<ul><li>Unrestricted state license as a Registered Nurse required; BSN preferred.</li><li>3+ (total) years clinical nursing experience</li><li>Utilization management experience in a managed care or hospital environment required</li><li>Certification in managed care nursing or care management desired (CMCN or CCM)</li></ul>Required License(s) and/or Certification(s):<ul><li>Unrestricted state license as a Registered Nurse</li></ul>Skills/Knowledge/Competencies (Behaviors):<ul><li>Demonstrates an understanding of and alignment with Martin’s Point Values.</li><li>Maintains current licensure and practices within scope of license for current state of residence.</li><li>Maintains contemporary knowledge of evidence - based guidelines and applies them consistently and appropriately.</li><li>Ability to analyze data metrics, outcomes and trends.</li><li>Excellent interpersonal, verbal and written communication skills</li><li>Critical thinking: can identify root causes and understands coordination of medical and clinical information</li><li>Ability to prioritize time and tasks efficiently and effectively</li><li>Ability to manage multiple demands</li><li>Ability to function independently</li><li>Computer proficiency in Microsoft Office products including Word, Excel, and Outlook</li></ul>This position is not eligible for immigration sponsorship.We are an equal opportunity/affirmative action employer.Do you have a question about careers at Martin’s Point Health Care? Contact us at: <a href="mailto:jobinquiries@martinspoint.org" target="_blank" rel="noopener noreferrer">jobinquiries@martinspoint.org</a>

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Common Interview Questions And Answers

1. HOW DO YOU PLAN YOUR DAY?

This is what this question poses: When do you focus and start working seriously? What are the hours you work optimally? Are you a night owl? A morning bird? Remote teams can be made up of people working on different shifts and around the world, so you won't necessarily be stuck in the 9-5 schedule if it's not for you...

2. HOW DO YOU USE THE DIFFERENT COMMUNICATION TOOLS IN DIFFERENT SITUATIONS?

When you're working on a remote team, there's no way to chat in the hallway between meetings or catch up on the latest project during an office carpool. Therefore, virtual communication will be absolutely essential to get your work done...

3. WHAT IS "WORKING REMOTE" REALLY FOR YOU?

Many people want to work remotely because of the flexibility it allows. You can work anywhere and at any time of the day...

4. WHAT DO YOU NEED IN YOUR PHYSICAL WORKSPACE TO SUCCEED IN YOUR WORK?

With this question, companies are looking to see what equipment they may need to provide you with and to verify how aware you are of what remote working could mean for you physically and logistically...

5. HOW DO YOU PROCESS INFORMATION?

Several years ago, I was working in a team to plan a big event. My supervisor made us all work as a team before the big day. One of our activities has been to find out how each of us processes information...

6. HOW DO YOU MANAGE THE CALENDAR AND THE PROGRAM? WHICH APPLICATIONS / SYSTEM DO YOU USE?

Or you may receive even more specific questions, such as: What's on your calendar? Do you plan blocks of time to do certain types of work? Do you have an open calendar that everyone can see?...

7. HOW DO YOU ORGANIZE FILES, LINKS, AND TABS ON YOUR COMPUTER?

Just like your schedule, how you track files and other information is very important. After all, everything is digital!...

8. HOW TO PRIORITIZE WORK?

The day I watched Marie Forleo's film separating the important from the urgent, my life changed. Not all remote jobs start fast, but most of them are...

9. HOW DO YOU PREPARE FOR A MEETING AND PREPARE A MEETING? WHAT DO YOU SEE HAPPENING DURING THE MEETING?

Just as communication is essential when working remotely, so is organization. Because you won't have those opportunities in the elevator or a casual conversation in the lunchroom, you should take advantage of the little time you have in a video or phone conference...

10. HOW DO YOU USE TECHNOLOGY ON A DAILY BASIS, IN YOUR WORK AND FOR YOUR PLEASURE?

This is a great question because it shows your comfort level with technology, which is very important for a remote worker because you will be working with technology over time...