Remote Utilization Review Registered Nurse

Overview

• Perform utilization review across inpatient, outpatient, and observation care levels remotely.
• Support a centralized Utilization Management department serving multiple healthcare facilities.
• Utilize clinical judgment and evidence-based guidelines to determine medical necessity.
• Adhere to California labor laws and work in Pacific Standard Time.
• Collaborate with interdisciplinary teams to coordinate patient care effectively.
• Manage a caseload of approximately 40 patients during day shifts.
• Participate in every-third-weekend rotation as part of the schedule.
• Enhance your expertise in Medicare regulations and managed care workflows.

Key Responsibilities & Duties

• Conduct concurrent, continued stay, pre-certification, prior authorization, and retrospective reviews.
• Determine medical necessity using InterQual criteria and evidence-based guidelines.
• Coordinate care and communicate effectively with interdisciplinary teams.
• Apply CMS, CPT/ICD-10 coding knowledge and regulatory standards.
• Support multiple facilities and rotate responsibilities as needed.
• Participate in every-third-weekend rotation as part of the schedule.
• Ensure compliance with HIPAA, Joint Commission standards, and CMS guidelines.
• Utilize Epic system for documentation and workflow management.

Job Requirements

• Associate of Science (AS) degree in Nursing or related field.
• Minimum 3 years of acute Care Management/Utilization Management experience in a hospital setting.
• Proficiency with InterQual criteria and Epic system within the last 6–12 months.
• Experience with Medicare regulations, UM processes, and managed care workflows.
• Strong understanding of HIPAA, Joint Commission standards, and CMS guidelines.
• Ability to work remotely in Pacific Standard Time and adhere to California labor laws.
• Preferred exposure to Pediatrics, ICU, Med-Surg, and ambulatory or acute hospital settings.
• Excellent clinical judgment and ability to manage a diverse patient population.