Utilization Review Nurse – Remote

About the role

The Utilization Review Nurse works remotely to evaluate the medical necessity and appropriateness of healthcare services for members. You will collaborate with providers, insurers, and patients to ensure high‑quality, cost‑effective care while adhering to company policies and regulatory standards.

Key responsibilities

• Conduct pre‑certification, inpatient, and retrospective reviews in line with UM policies.
• Perform initial medical necessity and benefit determination reviews, identifying cases that need further evaluation.
• Collaborate with healthcare providers to promote optimal member outcomes and maximize benefit utilization.
• Consult with the UM Medical Director on requests that do not meet medical necessity criteria.
• Execute continued stay reviews, care coordination, and discharge planning to ensure compliance with medical policies and member eligibility.
• Generate written correspondence to providers and members according to UM procedures.
• Maintain confidentiality and privacy in all communications.

Required profile

• Valid PHRN license (USRN license is a plus).
• Minimum 1 year of experience in Utilization Management.
• At least 2 years of clinical nursing experience in an ambulatory or hospital setting.
• Experience with managed care and health insurance environments.
• Ability to work holiday and weekend rotations.

Required skills

• Proficiency with Microsoft web‑based applications.
• Familiarity with UM criteria tools such as MCG and InterQual.

What we offer

• Fully remote work arrangement.
• Opportunity to impact patient care quality and cost efficiency.