(Remote – U.S.)
✅ Position Highlights
• 💼 Employment Type: Full-Time
• 🏡 Location: 100% Remote (U.S. only)
• 🩻 Department: Utilization Management
• 🧠 Role Type: Clinical RN – Telephonic & Concurrent Review
📋 What You’ll Own
• Conduct precertification reviews for inpatient/outpatient procedures
• Apply clinical judgment and UM criteria to determine medical necessity
• Collaborate with medical directors for complex case reviews
• Perform telephonic and concurrent reviews for hospitalizations
• Facilitate discharge planning and continuity of care
• Draft compliant denial communications and support appeal processes
• Educate providers on coverage determinations and managed care guidelines
• Document all clinical and provider interactions thoroughly in the UM system
• Identify members for case management programs and coordinate discharge services
• Assist with cost-benefit analyses for exceptional coverage cases
• Report potential quality issues, fraud, or abuse
• Collaborate with UM analysts on appeals, complaints, and inter-rater reviews
• Stay current with Medicaid manual updates and regulatory timelines
🎯 Must-Have Traits
• Active RN license in an eNLC (Enhanced Nurse Licensure Compact) state
• 3+ years of Nursing experience
• 1+ year of Utilization Management experience
• Skilled in reviewing clinical documentation, guidelines, and treatment plans
• Proficient in Microsoft Office and EMR systems
• Excellent organizational, time management, and communication skills
• Independent, self-motivated, and regulatory-compliant
💻 Remote Requirements
• Must reside in the United States
• Active eNLC RN license required
• Reliable high-speed internet and dedicated workspace
💡 Why It’s a Win for Remote Clinicians
This role combines clinical expertise with strategic decision-making in a fully remote setting. You’ll play a vital role in ensuring appropriate, quality care while maintaining work-life flexibility. Plus, you’ll help drive value-based healthcare outcomes without stepping away from your nursing roots.
✍️ Call to Action
If you’re a licensed RN with Utilization Management experience and a passion for delivering smart, patient-centered care from home—this is your opportunity. Apply now and help shape better healthcare delivery with every review you touch.