Registered Nurse - Utilization Review
Listed on 2026-10-20
-
Nursing
RN Nurse, Healthcare Nursing, Nurse Practitioner
Pay:
$45.00 - $51.00 per hour
Job description:
Position Details Position:
RN Utilization Management / Utilization Review Setting:
100% Remote
Schedule:
5x8-hour days
Hours:
8:00 AM 4:30 PM or 9:00 AM 5:30 PM
Pacific Time Weekend:
Every third weekend rotation
Typical Caseload:
Approximately 1:40
Equipment:
Laptop, keyboard, and mouse provided
Required Qualifications Active
California RN license Minimum
3 years of acute hospital Care Management/Utilization Management experience
Recent hospital-based Utilization Review experience required
Epic experience required
, with recent use within the last 6 12 months
Inter
Qual experience required Strong
Medicare knowledge required
Experience determining medical necessity and appropriate level of care Important:
Health plan or medical group UM experience alone does not meet the requirement. Candidates need acute hospital-based Care Management/UM experience.
Key Responsibilities Perform concurrent utilization reviews for inpatient, observation, and extended outpatient levels of care.
Review admissions and continued stays for medical necessity using
Inter Qual criteria
.Evaluate clinical documentation to determine appropriate level of care and continued stay.
Complete admission, concurrent, continued stay, and retrospective reviews.
Collaborate with physicians, Case Management, and multidisciplinary teams regarding utilization and medical necessity.
Review patient status and ensure compliance with Medicare and regulatory requirements.
Support care coordination and appropriate utilization of healthcare resources.
Manage prior authorization and pre-certification activities when applicable.
Review clinical information involving ICU, Medical-Surgical, pediatric, and other acute-care populations.
Maintain accurate and timely documentation within Epic.
Support centralized UM operations across three facilities and rotate assignments based on department needs.
Maintain productivity while managing a caseload of approximately 40 reviews/patients.
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