Utilization Management - RN

South Country Health Alliance

South Country Health Alliance is seeking a Utilization Management RN to join our team!

The RN Utilization Management nurse is a member of the UM team responsible for conducting medical necessity reviews for pre-service/prior authorization, post-service/retrospective reviews, and other assigned utilization reviews based on product requirements, service type, and organizational workflow. This role reviews clinical information, applies appropriate medical necessity criteria, and ensures coverage determinations are completed accurately and within required regulatory and organizational timeframes. The UM RN works collaboratively with providers, medical directors, internal departments, and other stakeholders to support appropriate, timely, and member-centered care.

This position involves a rotating on-call schedule, as required, to meet departmental and regulatory time frames during weekends and holidays.

QUALIFICATIONS:

What You’ll Bring:

• Current, valid, and unrestricted Minnesota RN License
• Three (3) years' clinical experience in a health care setting
• Experience with Microsoft Office Suite
• Strong written and verbal communication skills and the ability to multitask and balance priorities.
• Previous utilization management experience, experience in interpreting managed care benefit plans and strong knowledge of government programs (Medicare and Medicaid) is preferred.

Why South Country?

South Country Health Alliance is more than a health plan—we’re a mission-driven organization dedicated to improving health and well-being in rural Minnesota communities. Our work is guided by values of communication, collaboration, stewardship, and excellence, ensuring that every employee contributes to making a real difference in people’s lives. [mnscha.org]

We invest in our team with:

• Comprehensive benefits: Medical, dental, vision, life insurance, short- and long-term disability, pension (PERA), and more.
• Work-life flexibility: This position has on-site expectations.
• Predictable pay growth: Structured step-based salary system for transparency and stability. The pay for this position ranges from $34.39 - $47.94 per hour. This pay range represents the hourly rate for all positions in the job grade. The actual salary offer will depend on a variety of factors including experience, education, and other relevant factors.
• Join us and be part of an organization that values community impact, employee well-being, and innovation.

Must be legally authorized to work in the U.S. (No sponsorship available)

POSITION DESCRIPTION (Non-Exempt)

Utilization Management RN

Department: Health Services

Reports To: Health Services Manager

Pay Grade: Grade 8 Non Exempt

Supervises: None

Revision Date: 6/25/2026

JOB SUMMARY:

The RN Utilization Management nurse is a member of the UM team responsible for conducting medical necessity reviews for pre-service/prior authorization, post-service/retrospective reviews, and other assigned utilization reviews based on product requirements, service type, and organizational workflow. This role reviews clinical information, applies appropriate medical necessity criteria, and ensures coverage determinations are completed accurately and within required regulatory and organizational timeframes. The UM RN works collaboratively with providers, medical directors, internal departments, and other stakeholders to support appropriate, timely, and member-centered care.

This position involves a rotating on-call schedule, as required, to meet departmental and regulatory time frames during weekends and holidays.

QUALIFICATIONS:

Required: Current, valid, and unrestricted Minnesota RN License. Requires a minimum of 3 years’ clinical experience in a health care setting. Experience with Microsoft Office Suite. Strong written and verbal communication skills. Ability to multitask and balance priorities.

Preferred: Previous utilization management experience, experience in interpreting managed care benefit plans and strong knowledge of government programs (Medicare and Medicaid), experience interpreting and applying established clinical review criteria and guidelines such as State and Federal guidelines, InterQual, or internal health plan policies. Experience with telephonic communication and provider follow-up.

Skill Sets: Ability to interpret clinical records, apply critical thinking, and make sound clinical recommendations; strong clinical decision-making skills; clear written and verbal communication skills, especially with providers, members, and internal teams; strong attention to detail and accuracy in electronic clinical documentation; experience in electronic medical records; strong MS Word, Excel, and Outlook skills; ability to work independently and as part of a team; time management skills with the ability to prioritize and adjust to fluctuating workflows and changing assignments.

ESSENTIAL DUTIES and RESPONSIBILITIES:

The duties and responsibilities listed below reflect the general details necessary to describe the essential functions of the position and shall not be construed as the only duties that may be assigned for the position. % of Total Time

1. Accurately and consistently perform pre-service, concurrent, and post-service clinical reviews by applying established medical necessity criteria, guidelines, benefit requirements, and organizational policies. Utilize clinical judgment to evaluate treatment appropriateness and level of care, document review determinations clearly and in compliance with regulatory and professional standards and prepare and escalate cases to the Medical Director when required. 50%

2. Collaborates with members, clinic/hospital staff and other providers effectively to identify and obtain additional clinical information as needed to support complete, timely, and accurate review decisions within turnaround time requirements for all products. 15%

3. Maintains assigned workload and completes responsibilities within timelines established by regulatory requirements and departmental policies and procedures. 10%

5. Incorporates quality by identifying opportunities for refinement or improvement of the UM program, participating in continuous improvement process efforts, and successfully completing annual regulatory inter-rater reliability testing. 10%

6. Displays understanding of the organization’s products, benefits, provider network, and contracts, ensuring the member receives services through contracted providers as appropriate and available while minimizing out-of-network migration whenever possible. 5%

7. Collaborates with claims, the provider contact center, provider relations, and contracting on ad hoc provider education activities, and participates in committees or work groups as needed. 5%

8. Performs other duties as assigned. 5%

QUALIFICATION REQUIREMENT

An individual in this position must be able to successfully perform the essential duties and responsibilities listed above. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions of this position.

This position may be remote; however, occasional onsite attendance may be required for UM functions and department meetings.

LANGUAGE SKILLS

Must be able to read and write in English. Strong listening, verbal, presentation and written communication skills; Advanced language skills including inquiry skills to assure clear issue identification; Ability to articulate complex issues effectively to a variety of audiences; Writing that is clear and to the point; Chooses the appropriate method of communication to meet customer and organizational needs

MATHMATICAL SKILLS

Mathematical skills. Basic understanding of quality and financial data reporting. Analytic skills required.

ACCURACY

Considerable accuracy and dependability required. Must be attentive to the critical impact of policies, decisions and program design on our members, providers, and the overall image of the organization.

REASONING ABILITY

Must understand cause and effect relationships and be able to draw conclusions from data, regulatory requirements, and past practice; Requires strong critical thinking and keen judgment when addressing involved and complex issues; Devises methods and procedures to meet unusual conditions and makes original contributions to the solution of very difficult problems; Demonstrated complex problem-solving skills with effective follow through to address highly critical issues; Ability to think strategically.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to talk or listen. The employee frequently is required to sit, sometimes for extended periods of time. The employee is occasionally required to stand, walk, kneel; use hands to finger, handle, or feel objects, tools, or controls; and reach with hands and arms.

The employee must rarely lift and/or move up to ten pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception, and the ability to adjust focus.

CONTACTS/RELATIONSHIPS

This position works internally with most departments and works closely with related external TPA’s and contract providers, South Country members, county, state and federal business partners, as well as some community organizations.

Maintains satisfactory relationships; may include collaboration in executing established policies, discussion of ways to reach agreed-upon objectives, securing compliance with approved procedures.

FINANCIAL IMPACT

This position is responsible for ensuring that South Country is following contract language as promulgated by governmental agencies. Failure to comply with this contractual language could result in breach of contract resulting in a significant financial penalty, potential contract cancellation, sanctions, and/or corrective action.

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