Remote Utilization Review Registered Nurse

Overview

• Provide remote utilization review services for an acute hospital setting, ensuring compliance with healthcare regulations and standards.
• Collaborate with healthcare teams to manage patient care plans and optimize resource utilization effectively.
• Perform concurrent and continued stay reviews to ensure appropriate patient care and resource allocation.
• Support three facilities, adhering to California labor laws and working in Pacific Standard Time.
• Conduct audits and retrospective reviews to maintain compliance with CMS and other regulatory standards.
• Utilize InterQual criteria and Epic systems for efficient case management and utilization review processes.
• Engage in appeals and denials processes to ensure accurate and fair patient care decisions.
• Maintain strict adherence to HIPAA and other healthcare privacy regulations.

Key Responsibilities & Duties

• Perform utilization reviews to assess medical necessity and appropriateness of patient care.
• Collaborate with healthcare providers to develop and implement effective care management plans.
• Conduct audits and retrospective reviews to ensure compliance with healthcare regulations.
• Manage appeals and denials processes, providing detailed documentation and support.
• Utilize Epic and InterQual systems for efficient case management and review processes.
• Ensure adherence to CMS, HIPAA, and other regulatory requirements in all activities.
• Support multiple facilities, adapting to diverse patient demographics and needs.
• Provide weekend coverage as required, maintaining high standards of care management.

Job Requirements

• Bachelor of Science in Nursing (BSN) with active RN licensure.
• Minimum of 2 years of acute care management and utilization review experience.
• Proficiency in Epic and InterQual systems within the last 6–12 months.
• Knowledge of Medicare regulations, CPT coding, ICD-10, and Medi-Cal processes.
• Familiarity with CMS, HIPAA, and other healthcare regulatory standards.
• Strong skills in audits, appeals, denials, and retrospective reviews.
• Ability to work remotely in Pacific Standard Time and support multiple facilities.
• Preferred certifications in NCQA, OSHA, and Worker’s Compensation.