UM Clinical Specialist, RN – Physical Health

Alliance Health

UM Clinical Specialist RN assessing medical necessity for physical health services. Collaborating cross-agency to ensure consumers access appropriate treatment resources.

Posted 7/23/2026full-timeMorrisville • North Carolina • 🇺🇸 United StatesMid-LevelSenior💰 $68,227 - $86,990 per yearWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in medical necessity assessments, utilization management, and compliance with clinical practice guidelines. Holds a current North Carolina Registered Nurse license and possesses extensive nursing experience, ensuring adherence to performance measures and standards.

Highest-signal resume keywords

Medical Necessity AssessmentUtilization ManagementClinical Practice GuidelinesRegistered Nurse LicenseNursing Experience

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Nursing ExperienceMedical Necessity ReviewsUtilization ReviewsDiagnostic Treatment GuidelinesLevel of Care Criteria

Tools & Technologies

Computer ProficiencySoftware Programs

Certifications & Qualifications

North Carolina Registered Nurse LicenseCompact License

Industry Keywords

Accrediting Body StandardsAdverse Benefit DeterminationsDue Process RightsCo-Morbid Health Conditions

About the role

Key responsibilities & impact

Assesses the medical necessity of services
Independently conduct medical necessity reviews of service requests
Ensure authorized services address service needs, intensity of service outcomes, and alternatives for consumers
Conduct pre-certification, concurrent, and retrospective reviews to ensure compliance
Conduct utilization reviews to monitor adherence to clinical practice guidelines
Notify members of adverse benefit determinations while preserving members’ Due Process rights
Ensure compliance with performance measures outlined within all accrediting body standards

Requirements

What you’ll need

Graduation from a State accredited school of nursing or an Associate’s Degree in Nursing from an accredited
5 years of nursing experience OR Bachelor’s degree in Nursing from an accredited college/university and 3 years of nursing experience
Current, active, and unrestricted North Carolina clinical license as a Registered Nurse, or a compact license
Experience in Utilization Management
Knowledge of physical health and co-morbid health conditions
Knowledge of diagnostic treatment guidelines/protocols, level of care criteria
Proficient in the use of computer and multiple software programs.

Benefits

Comp & perks

Medical, Dental, Vision, Life, Long Term Disability
Generous retirement savings plan
Flexible work schedules including hybrid/remote options
Paid time off including vacation, sick leave, holiday, management leave
Dress flexibility