Utilization Review RN; Remote

Are you an experienced RN looking to transition away from the bedside while still making a massive impact on patient care? We are seeking a dedicated Utilization Review Nurse to join our remote team. In this role, you will act as a vital bridge between clinical care and hospital operations, ensuring patients receive the right level of care while safeguarding revenue integrity.

With a compressed 4-day work week, remote flexibility, and highly lucrative shift differentials, this role is designed for nursing professionals who value both operational excellence and a genuine work-life balance.

We believe in rewarding our team for their hard work and flexibility.

• Salary Range: $63,000 - $94,000 annually (dependent upon experience, education, certifications, and overall qualifications).
• The
  
  Schedule:
  
  Enjoy three days off a week! This role features a 4x10 schedule (four 10-hour shifts per week). You will work every other weekend on a rotating basis.
• Shift Options: 10:00 a.m.
  
  - 8:00 p.m.
  OR 12:00 p.m.
  
  - 10:00 p.m. (Candidates must be flexible to work either shift based on business needs).
• 10% Weekend Differential for any hours worked on a weekend.
• 10% Evening Differential for hours worked during the 12:00 p.m.
  
  - 10:00 p.m. shift.
• Bonus:
  These differentials compound! If you work the 12:00 p.m.
  
  - 10:00 p.m. shift on a weekend, you can earn a 20% premium on your base pay for those eligible hours.
• Total Rewards: Bonus incentives, Paid Certifications, Tuition Reimbursement, Comprehensive Health Benefits, and clear pathways for Career Advancement.

• Medical Necessity & Clinical Review: Utilize approved clinical criteria to determine the medical necessity of all admissions, ensuring appropriate patient status and continued stay reviews.
• Resource Utilization: Identify proactive triggers (diagnoses, cost criteria, complications) to monitor the over/under-utilization of healthcare services, and initiate timely physician advisor referrals.
• Denial Management & Appeals: Coordinate the Peer-to-Peer (P2P) process with physicians and Revenue Cycle teams. Monitor denial trends, record updates, and maintain robust documentation to minimize denial rates.
• Revenue Integrity & Quality: Accurately manage Connect Care and ADT work queues, record statistical data, and help achieve outcomes management goals, including CMS indicators.
• Collaborative Communication: Partner daily with in-house care managers, the Financial Clearance Center (FCC), patient access, and business offices to resolve billing issues related to third-party payers.
• Process Innovation: Actively participate in process improvement initiatives, remaining inquisitive and open to utilizing new technologies (including AI) to streamline workflows and improve the patient/client experience.

• Education & Licensure: Bachelor’s Degree in Nursing (or equivalent experience). Must hold a current, unrestricted RN license. A current compact RN license is highly preferred, or you must be willing to obtain one.
• Experience: At least 3 years of nursing experience in an acute care environment is strongly preferred. Previous experience in utilization review, discharge planning, or working with medical necessity criteria is highly desired.
• Skills: Exceptional clinical assessment, problem-solving, and organizational skills. You must be able to confidently negotiate and communicate with physicians, payers, and multidisciplinary healthcare teams.
• Remote Work Readiness: This is a remote role requiring reliable high-speed internet and the ability to maintain professional, prompt communication via VoIP, Skype, email, and designated devices.
• Flexibility: While primarily remote, candidates must be willing and able to travel to work onsite at client or corporate office locations occasionally, as business needs require.