Remote Utilization Review Registered Nurse

Overview

• Provide remote utilization review services to support prior authorization and utilization management functions within a healthcare organization.
• Evaluate clinical documentation, applying evidence-based medical necessity criteria and CMS guidelines to ensure compliance.
• Collaborate with multidisciplinary teams to coordinate effective care and resolve clinical issues.
• Develop individualized case management plans addressing clinical and psychosocial needs.
• Participate in performance improvement initiatives and departmental projects to enhance service delivery.
• Communicate medical necessity and level-of-care criteria to providers and payers effectively.
• Utilize advanced clinical judgment and analytical skills in a high-volume environment.
• Work independently while maintaining collaboration with interdisciplinary teams.

Key Responsibilities & Duties

• Review and evaluate clinical documentation for prior authorization requests.
• Apply evidence-based medical necessity criteria, CMS guidelines, and health plan policies.
• Interpret clinical data from medical records and electronic systems accurately.
• Coordinate clinical resolutions with physicians and other clinicians as needed.
• Serve as a resource for internal teams such as customer service and claims.
• Collaborate with multidisciplinary teams to ensure safe, effective care coordination.
• Participate in performance improvement initiatives and departmental projects.
• Communicate medical necessity and level-of-care criteria to providers and payers.
• Develop individualized case management plans addressing clinical and psychosocial needs.

Job Requirements

• Active, unrestricted California RN license and Bachelor of Science in Nursing (BSN).
• Prior authorization experience in outpatient or health-plan settings.
• Proficiency with evidence-based medical necessity criteria and CMS guidelines.
• Strong written and verbal communication skills and ability to work independently.
• Experience with managed-care platforms and computer proficiency.
• Preferred experience includes utilization management, Medicare/Medi-Cal familiarity, and discharge planning.
• Background in handling high-acuity patient populations across all age groups.
• Ability to collaborate effectively with interdisciplinary teams.
• BLS certification and proficiency with Epic systems.