Utilization Review Nurse – RN

This is a fully remote position, open to applicants in United States.

📋 Description

• Assess requested services against benefits language, medical policies, and widely recognized criteria such as MCG and NCCN.

• Identify the suitable level of care while adhering to state and federal regulations.

• Forward cases that fail to meet the criteria to the Medical Director for secondary clinical evaluation.

• Guarantee that adverse determinations are made promptly, defensibly, and in alignment with NCQA/URAC accreditation standards.

• Review clinical documentation for thoroughness and recognize acuity, risk indicators, discrepancies, and gaps.

• Initiate outreach or escalation when documentation-related issues are detected.

• Manage caseloads based on urgency, regulatory deadlines, and member implications.

• Verify eligibility, benefits, authorization, and network status.

• Guide members towards in-network, benefit-compliant alternatives when clinically suitable.

• Prepare clinical summaries and documentation for appeals.

• Facilitate peer-to-peer discussions with physicians and manage appeals, including IRO referrals.

• Record reviews, justifications, criteria citations, and outcomes in UM systems in real time.

• Achieve productivity, quality, accuracy, and turnaround benchmarks.

• Engage in calibration activities and incorporate feedback.

• Uphold HIPAA compliance and complete necessary training and annual competencies.

• Cross-train and offer coverage support as needed.

⛳️ Requirements

• Active, unrestricted RN license in the United States or a U.S. territory; compact license accepted where applicable.

• Graduate from an accredited nursing program; an ADN or diploma is required, with a BSN preferred.

• 1–2+ years of recent clinical experience in acute care, med-surg, ICU/ED, or a comparable environment.

• Experience in utilization review/utilization management is preferred.

• Proficient in Microsoft Word, Excel, and Outlook.

• Familiarity with ICD-10, CPT, and HCPCS coding and medical claims.

• Capability to interpret medical records and apply evidence-based criteria and medical policies.

• Comfortable working across multiple screens and systems with strong typing skills.

• Ability to operate independently within UM platforms and workflows post-training.

• Availability to work Monday–Friday, 8:00 AM–5:00 PM Pacific Time, with rotating Saturday coverage as needed.

• Adherence to HIPAA compliance and confidentiality using minimum-necessary standards.

🏝️ Benefits

• Competitive base salary.

• Comprehensive medical and dental coverage through our own health solutions.

• Paid Time Off.

• Mental health support.

• Retirement planning.

• Financial protection.

• Professional development opportunities with clear career progression and learning budgets.

• A mission-driven culture where diverse perspectives lead to significant impact.

• Wellness programs.

• Additional employee perks.

• Full benefits package effective from day one.