Utilization Management Nurse Practitioner - NJ

Toney Healthcare is looking for a licensed Nurse Practitioner in NJ with 3+ years of managed care experience to join our Utilization Management team! If you're passionate about ensuring the right care at the right time, this role is for you.

Why Join Us?

✅ Fully Remote – Work from anywhere

✅ Monday-Friday Schedule – 40-hour workweek, no weekends

✅ Impactful Work – Facilitate medical reviews, collaborate with providers, and ensure quality care

✅ Competitive Pay & Growth – Gain experience with industry-leading UM processes

What You’ll Do:

🔹 Conduct pre-service, concurrent, and retrospective reviews using MCG Criteria

🔹 Coordinate medical necessity determinations and communicate approvals/modifications

🔹 Collaborate with physicians, providers, and care teams for optimal patient outcomes

🔹 Identify high-risk cases and escalate quality concerns as needed

What We’re Looking For:

✔ Active NJ RN License (required)

✔ 3+ years of Utilization Management experience in a health insurance setting

✔ Strong understanding of MCG Criteria & care management platforms

✔ UM certification & Behavioral Health experience are a plus!

Interested? Apply now: Careers — Toney Healthcare