**Utilization Management Nurse / Social Worker (Contract Position)** 📍 **Location:** Remote (Must Train Onsite for 1-2 Weeks) – Must Reside Within 3 Hours of Client Location 💰 **Max Pay Rate:** $23.00/hr ⏳ **Schedule:** Monday – Friday, 8:30 AM – 5:00 PM 🖥 **Interview Format:** Microsoft Teams **Job Overview** We are seeking a **Utilization Management Nurse or Licensed Social Worker** to perform medical reviews and utilization management for professional, inpatient, and outpatient services. This role requires strong analytical skills, attention to detail, and the ability to effectively communicate with members and healthcare providers. **Key Responsibilities** ✔ **Medical Review & Utilization Management (80%)** + Perform medical reviews using established criteria and guidelines. + Review medical claims and determine reasonable charge payments. + Ensure authorization of medical services based on benefit guidelines. + Review interdepartmental requests for medical information to support utilization processes. + Conduct high-dollar forecasting and patient health summaries. + Assess risk and determine eligibility and medical necessity of services. + Handle first-level appeals, ensuring detailed documentation of determinations. ✔ **Education & Communication (10%)** + Provide education to internal/external staff on medical reviews, terminology, coverage determinations, and coding procedures. + Communicate determinations clearly and accurately to members and providers. ✔ **Quality Control & Training (10%)** + Participate in corporate quality control initiatives. + Complete required training and support team-based objectives. **Required Qualifications** 🎓 **Education:** + **Bachelor’s degree** in Social Work **OR** Graduate of an Accredited School of Licensed Practical Nursing (LPN) or Licensed Vocational Nursing (LVN). 💼 **Experience:** + Minimum **2 years of clinical experience** in a healthcare setting. 📜 **Licenses & Certifications:** + **Active, unrestricted** LPN/LVN license **OR** LBSW (Licensed Bachelor of Social Work) in the U.S. and state of hire. **Preferred Qualifications** 🎓 **Education:** + Associate Degree in Nursing **OR** Graduate of an Accredited School of Nursing. 📜 **Licenses & Certifications:** + **Active, unrestricted** RN license **OR** compact multistate RN license (NLC). 🖥 **Software & Tools:** + **Required:** Microsoft Office, strong typing and computer skills. + **Preferred:** Microsoft Excel, Access, or other database/spreadsheet software. **Key Soft Skills** ✅ Detail-oriented and highly organized. ✅ Strong communication and interpersonal skills. ✅ Effective time management and prioritization. ✅ Ability to work independently and as part of a team. **Work Environment & Team Culture** + Remote role after **1-2 weeks of onsite training** . + Highly collaborative team of **22 nurses** , working closely with other utilization management teams. + Supportive, team-oriented culture with ongoing professional development opportunities. **Typical Day in This Role** + Log in at **8:30 AM** , review workload, and prioritize tasks. + Process electronic faxes and phone requests. + Review requests against policies and member contracts. + Determine if a case can be handled at the current level or needs escalation. + Complete approvals or denials and notify providers accordingly. **Interview & Hiring Process** + Virtual interview via **Microsoft Teams** . + Must **train onsite** before transitioning to **remote work** . If you meet the qualifications and are interested in joining a **collaborative** and **mission-driven** team, apply today! ManpowerGroup is committed to providing equal employment opportunities in a professional, high quality work environment. It is the policy of ManpowerGroup and all of its subsidiaries to recruit, train, promote, transfer, pay and take all employment actions without regard to an employee's race, color, national origin, ancestry, sex, sexual orientation, gender identity, genetic information, religion, age, disability, protected veteran status, or any other basis protected by applicable law.