Utilization Review Nurse, RN – Part-Time

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

📋 Description

• Conduct medical necessity reviews and level-of-care assessments for requested services in utilization management.

• Utilize benefit language, plan documents, medical policies, evidence-based criteria such as MCG and NCCN, along with state and federal regulations.

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

• Review clinical documentation for thoroughness and identify risk factors, acuity indicators, discrepancies, or missing details.

• Promptly initiate outreach and escalation in line with the utilization management workflow.

• Organize workload based on urgency, regulatory/accreditation timelines, and the impact on members.

• Assist with compliant redirection within the network by verifying eligibility, benefits, authorization prerequisites, and network status.

• Aid in appeals by compiling clinical summaries and documentation, as well as coordinating peer-to-peer or Medical Director discussions.

• Record reviews, rationale, criteria or policy references, communications, and outcomes in the designated utilization management systems.

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

• Engage in calibration and quality assurance activities while integrating feedback.

• Uphold HIPAA compliance and confidentiality standards.

• Complete necessary training and annual competency evaluations.

• Provide cross-training and cross-coverage to facilitate team operations and meet service-level expectations.

⛳️ Requirements

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

• Graduate from an accredited nursing program; an ADN or diploma is required.

• BSN is preferred.

• At least 1–2 years of recent clinical experience, including acute care, med-surg, ICU/ED, or a similar setting.

• Prior experience in utilization review/utilization management is preferred.

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

• Basic computer skills are required upon hire.

• Ability to work across multiple screens and proficient typing skills are necessary.

• Proficient in Microsoft Word, Microsoft Excel, Outlook, and comparable software applications.

• Strong verbal and written communication skills.

• Able to convey complex or technical information clearly and comprehend intricate information from others.

• Ability to work independently and utilize written resources to address problems.

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

• Capacity to perform essential job functions safely and effectively, with or without reasonable accommodation.

• Dependable with regular and punctual attendance.

• Ability to sit for 6–8 hours.

• Frequent use of computer keyboard and mouse with repetitive hand movements.

• Occasional to frequent neck twisting and occasional bending of the neck and waist may be required.

• Weekend availability is required.

• Availability for up to 28 hours per week.

🏝️ Benefits

• Competitive base salary and benefits effective from day one.

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

• Paid Time Off.

• Mental health support.

• Retirement planning.

• Financial protection.

• Opportunities for professional development with clear career advancement and learning budgets.

• Mission-driven culture where diverse perspectives create genuine impact.

• Wellness programs.

• Additional employee perks.

• Full benefits package commencing on day one.