Utilization Review Nurse

in Healthcare + Life Sciences Contract

Job Detail

  • Experience Level Mid Level
  • Degree Type Associate of Science (AS)
  • Employment Full Time
  • Working Type Remote
  • Job Reference 0000011157
  • Salary Type Hourly
  • Industry Hospital
  • Selling Points

    FULLY REMOTE ROLE . Must have XSOLIS/Dragonfly experience and 1 year working in remote UR role recently to be considered.

Job Description

Key Responsibilities:

  • Conduct timely and accurate reviews of inpatient and outpatient medical records to determine medical necessity and level of care.
  • Apply evidence-based criteria (e.g., InterQual, MCG) and hospital policies to support clinical decision-making.
  • Communicate with physicians and clinical staff to clarify documentation and support utilization decisions.
  • Submit clinical reviews to insurance companies and respond to requests for additional information.
  • Monitor patient status and ensure appropriate documentation for continued stay reviews.
  • Maintain compliance with federal, state, and payer-specific regulations.
  • Accurately document all review activities in the hospital’s electronic medical record (EMR) and UR platforms (e.g., XSOLIS/Dragonfly).

Qualifications:

  • Active and unrestricted Registered Nurse (RN) license in the state of California.
  • Minimum of 2 years of recent Utilization Review experience, with at least 1 year of remote UR experience within the last 12 months.
  • Proficiency with XSOLIS/Dragonfly platforms.
  • Strong knowledge of utilization management principles and payer requirements.
  • Excellent critical thinking, communication, and time management skills.
  • Ability to work independently in a remote environment with minimal supervision.

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