RN – Utilization Management (Fully Remote)

Job Overview

We are seeking a highly motivated and detail-oriented Registered Nurse (RN) specializing in Utilization Management to join our dynamic healthcare team. This fully remote position offers an exciting opportunity to impact patient care by evaluating medical necessity, reviewing clinical documentation, and ensuring compliance with healthcare regulations. As an RN in Utilization Management, you will collaborate with multidisciplinary teams to optimize patient outcomes, manage resources effectively, and uphold the highest standards of clinical documentation and coding accuracy. Your expertise will support the delivery of efficient, compliant, and patient-centered care across various healthcare settings.

Responsibilities

• Conduct thorough reviews of medical records, clinical documentation, and treatment plans to determine medical necessity in accordance with CMS (Centers for Medicare and Medicaid Services) guidelines and other regulatory standards.
• Utilize EMR (Electronic Medical Records) systems such as Epic, Cerner, Athenahealth, or similar platforms to document findings accurately and efficiently.
• Collaborate with healthcare providers to clarify documentation gaps, ensure accurate coding (CPT, ICD-9, ICD-10), and support appropriate utilization review processes.
• Evaluate inpatient and outpatient records across diverse settings including acute care, ICU, long-term care facilities, nursing homes, hospice care, emergency medicine, and outpatient clinics.
• Apply knowledge of hospital experience, trauma center protocols (Level I/II), discharge planning procedures, and home care regulations to facilitate appropriate patient management.
• Ensure compliance with HIPAA (Health Insurance Portability and Accountability Act), state healthcare regulations, and NCQA (National Committee for Quality Assurance) standards during all documentation review activities.
• Assist in clinical documentation improvement initiatives by identifying opportunities for enhanced accuracy and completeness of medical records.
• Support case management efforts by reviewing utilization patterns for appropriateness and supporting long-term care or hospice services as needed.

Skills

• Proficiency with EMR/EHR systems such as Epic, Cerner, Athenahealth, or similar platforms; experience with electronic health records management is essential.
• Strong knowledge of medical terminology, anatomy, physiology, and clinical documentation standards to accurately interpret complex medical records.
• Familiarity with CPT coding procedures, ICD coding (ICD-9/ICD-10), DRG assignment, MDS assessments for long-term care facilities, and HEDIS measures.
• In-depth understanding of Medicare regulations, CMS policies, HIPAA compliance requirements, and state healthcare laws affecting utilization management.
• Critical care experience including ICU or trauma center background is highly preferred; inpatient or emergency medicine experience is advantageous.
• Knowledge of managed care processes along with outpatient clinic experience enhances your ability to evaluate diverse patient cases effectively.
• Excellent communication skills for collaborating with multidisciplinary teams and providing clear documentation reviews; proficiency in Microsoft Office tools is required.
• Ability to analyze clinical data critically while maintaining attention to detail; strong organizational skills to manage multiple cases efficiently.

Join us in transforming healthcare delivery through expert utilization management! Your dedication will help ensure patients receive appropriate care while maintaining compliance with all regulatory standards—making a meaningful difference every day from the comfort of your home office.

Pay: $1,800.12 - $19,000.12 per week

Work Location: In person