Virtual Utilization Review RN - 259398

Registered Nurse – Utilization Review

Position Overview

We are seeking an experienced Registered Nurse (RN) to join our Utilization Review team in a remote capacity. This role is responsible for evaluating medical necessity, reviewing levels of care, supporting denial prevention and appeals, and promoting appropriate resource utilization across the continuum of care.

The ideal candidate has a strong clinical background, excellent critical-thinking skills, and the ability to collaborate effectively with physicians, care managers, insurance carriers, and interdisciplinary teams. This individual will play an important role in supporting quality patient outcomes, regulatory compliance, and revenue integrity.

This is an excellent opportunity for a clinically experienced RN looking to apply their expertise in utilization review, care coordination, and healthcare resource management.

Key Responsibilities

Utilization Review & Medical Necessity

• Conduct admission, continued-stay, and observation reviews to evaluate medical necessity and appropriate levels of care using established clinical criteria.
• Identify potential overutilization, underutilization, and barriers to patient progression through proactive clinical review.
• Submit required clinical documentation to insurance carriers and the Financial Clearance Center within one business day of admission.
• Coordinate physician advisor referrals and second-level reviews while collaborating with providers and care managers to obtain supporting documentation.
• Apply clinical judgment and evidence-based criteria to evaluate patients across all age groups and levels of care.

Denial Management & Revenue Integrity

• Coordinate peer-to-peer (P2P) reviews and appeals in collaboration with physicians, the Financial Clearance Center, and Revenue Cycle teams.
• Maintain accurate documentation of denials, appeals, overturned days, and review outcomes.
• Monitor readmissions and identify trends that may impact denial rates and revenue cycle performance.
• Manage assigned ConnectCare and Admission, Discharge, and Transfer (ADT) work queues to support accurate billing and timely processing.
• Collaborate with Patient Access, Financial Counselors, and Business Office teams to resolve payer-related billing concerns and communicate non-coverage determinations.

Communication & Collaboration

• Partner with physicians, nursing staff, care managers, and leadership to support appropriate patient care and resource utilization.
• Provide education to hospital and medical staff regarding utilization review processes, regulatory requirements, and payer guidelines.
• Maintain timely and professional communication with internal teams and external stakeholders.
• Navigate challenging conversations and resolve conflicts with professionalism and a solutions-oriented approach.

Quality Improvement & Compliance

• Contribute to departmental quality improvement initiatives, committee meetings, and process improvement efforts.
• Maintain accurate statistical records and complete assigned administrative responsibilities within established deadlines.
• Support team members during high-volume periods and assist with coverage needs as appropriate.
• Maintain clinical competency and adhere to HIPAA, confidentiality standards, patient rights, and organizational policies.
• Identify opportunities to improve workflows through technology, including AI-enabled solutions where appropriate.

Required Qualifications

• Current, unrestricted Registered Nurse (RN) license; compact RN license preferred.
• Clinical nursing experience in an Intensive Care Unit (ICU), Emergency Department (ED), or Operating Room (OR).
• Working knowledge of quality improvement processes.
• Strong clinical assessment, critical-thinking, and problem-solving skills.
• Excellent written and verbal communication skills, including the ability to collaborate and negotiate with physicians, payers, and multidisciplinary teams.
• Strong organizational skills with the ability to prioritize competing responsibilities in a fast-paced environment.
• Ability to work independently, exercise sound judgment, and take initiative.
• Commitment to providing excellent customer service to patients, providers, and internal stakeholders.
• Reliable high-speed internet access for remote work.
• Willingness and ability to travel to corporate, client, or temporary onsite locations as business needs require.

Preferred Qualifications

• Five or more years of Utilization Review (UR) nursing experience.
• Pediatric nursing experience.
• Experience using InterQual clinical criteria or review systems.

Schedule & Shift Options

This position follows a four-day, 10-hour shift schedule, with every other weekend required.

Available shifts:

• Day/Evening Shift: 10:00 a.m. – 8:00 p.m.
• Evening Shift: 12:00 p.m. – 10:00 p.m.

Compensation & Benefits

In addition to competitive base pay and a comprehensive benefits package, this position offers additional shift differentials:

• 10% Weekend Differential: Applies to hours worked on weekends.
• 10% Evening Differential: Applies to the 12:00 p.m. – 10:00 p.m. shift.
• Stackable Differentials: Eligible employees working evening hours on weekends can earn a combined 20% differential on top of their base rate.

Why Join This Team?

• Remote work opportunity with structured scheduling.
• Four 10-hour shifts per week, providing an additional day off.
• Additional earning potential through weekend and evening shift differentials.
• Opportunity to apply clinical nursing expertise outside traditional bedside care.
• Collaborative environment focused on patient outcomes, quality improvement, and appropriate healthcare resource utilization.