Utilization Review RN

This position is listed on behalf of a partner company, which manages all applications and next steps. Our partner is looking for a Utilization Review RN based in the United States. Join a healthcare team dedicated to improving patient outcomes, ensuring appropriate resource utilization, and supporting the financial integrity of hospital operations. In this part-time, remote role, you will apply your clinical expertise to evaluate medical necessity, review patient admissions, and ensure care aligns with established clinical criteria and payer requirements. Working closely with physicians, care managers, insurance representatives, and revenue cycle professionals, you will help resolve utilization concerns and minimize claim denials. You will also contribute to quality improvement initiatives, regulatory compliance, and effective care coordination across a diverse patient population. The position offers flexible part-time scheduling options, with shifts distributed across a seven-day coverage schedule. It is an excellent opportunity for a registered nurse who combines strong clinical judgment with analytical skills and a commitment to high-quality, cost-effective healthcare.

Medical necessity reviews: Conduct clinical reviews of inpatient admissions, observation stays, and continued hospital stays using approved medical necessity criteria to determine appropriate patient status and level of care. Utilization management: Identify potential overutilization or underutilization of healthcare services by evaluating diagnoses, costs, complications, and clinical indicators. Refer cases to physician advisors when necessary. Clinical documentation and coordination: Collaborate with physicians, in-house care managers, and interdisciplinary teams to clarify clinical information, obtain supporting documentation, and address barriers to patient progress. Payer communication: Complete and submit clinical reviews for commercial insurance carriers to the Financial Clearance Center within the required timeframe, generally one business day after admission. Communicate review outcomes promptly to relevant stakeholders. Denial prevention and management: Maintain accurate documentation to minimize claim denials, coordinate peer-to-peer discussions and appeals when assigned, track overturned days, monitor denial trends, and identify opportunities for improvement. Revenue cycle collaboration: Work with financial clearance, patient access, financial counseling, and business office teams to resolve billing concerns involving third-party payers and support revenue integrity. Patient care facilitation: Prioritize reviews based on clinical assessments, medical records, patient needs, and applicable review criteria. Maintain effective communication with care management teams to support appropriate and timely care decisions. Quality improvement: Support quality and performance initiatives, including applicable Centers for Medicare & Medicaid Services (CMS) indicators. Participate in departmental improvement projects and help strengthen utilization review processes. Data management and reporting: Maintain accurate statistical records, complete assigned system work queues, document communications and review outcomes, and submit required information within established deadlines. Physician and stakeholder communication: Communicate coverage and non-coverage determinations to physicians and patients as appropriate. Provide education to hospital and medical staff regarding utilization review requirements and procedures. Teamwork and collaboration: Maintain positive working relationships with physicians, nurses, multidisciplinary teams, and administrative stakeholders. Provide backup support to colleagues and contribute to shared departmental goals. Compliance and professional development: Follow departmental policies, protect patient confidentiality and rights, and maintain current knowledge of medical necessity criteria, payer requirements, MS-DRGs, present-on-admission indicators, and relevant regulations. Continuous improvement and innovation: Participate in meetings, training, committees, and process improvement initiatives. Remain open to innovative approaches, including AI-enabled tools, that improve efficiency and the patient and client experience. Additional responsibilities: Perform other related duties as assigned. Although the role is remote, occasional travel to client, temporary, or corporate offices may be required based on business needs. Requirements Education: Bachelor's degree in nursing or a related field, or equivalent relevant education and experience. Licensure: Current, unrestricted Registered Nurse (RN) license. An active multistate compact RN license is preferred; candidates must already hold one or be willing to obtain one. Clinical experience: Three years of nursing experience in an acute care setting is preferred. Utilization review expertise: Previous experience in utilization review, discharge planning, medical necessity assessments, or related care management functions is an advantage. Clinical criteria knowledge: Recent experience or working knowledge of medical necessity review criteria, inpatient and observation status determinations, payer guidelines, and continued-stay reviews is preferred. Quality improvement: Working knowledge of healthcare quality improvement processes and the ability to identify opportunities to improve clinical and operational outcomes. Clinical assessment and analytical skills: Strong clinical judgment, critical thinking, problem-solving abilities, and the capacity to interpret medical records and determine appropriate resource utilization. Communication and negotiation: Excellent interpersonal, written, and verbal communication skills, with the ability to collaborate effectively with physicians, insurance payers, care managers, and other healthcare professionals. Organizational abilities: Strong time management, prioritization, and documentation skills, including the ability to manage multiple reviews and competing deadlines in a fast-paced environment. Independent working style: Resourcefulness, initiative, attention to detail, and the ability to work independently while remaining responsive to team members and stakeholders. Patient and client focus: A strong commitment to customer service, patient-centered decision-making, appropriate care delivery, and positive working relationships. Technology and remote work: Comfortable using digital communication platforms, electronic documentation systems, and clinical review tools. Reliable access to high-speed internet is required. Adaptability and innovation: Willingness to explore new technologies and AI-enabled processes that reduce administrative friction and improve service quality. Schedule flexibility: Ability to work within the department's coverage hours of 8:00 a.m. to 10:00 p.m., including rotating weekends, according to business needs. Travel availability: Willingness and ability to travel to and work at client, temporary, or corporate locations when required. Work authorization: Must reside in and be legally authorized to work in the United States. Benefits Competitive compensation: Annualized salary range of $63,100–$94,650 , depending on experience, education, certifications, and qualifications. Actual compensation will reflect the applicable part-time schedule and employment terms. Part-time scheduling: Options for approximately 20 or 24 hours per week, with a choice of shift combinations designed to support flexibility and work-life balance. Weekend differential: Additional 10% pay for eligible hours worked on weekends. Evening shift differential: Additional 10% pay for eligible hours worked between 12:00 p.m. and 10:00 p.m. Combined premium pay: Eligible hours worked during the evening shift on weekends may qualify for a combined differential of up to 20%. Comprehensive benefits: Access to a benefits package supporting physical, emotional, and financial well-being, subject to eligibility and plan terms. Healthcare coverage: Medical and other applicable healthcare benefits, depending on eligibility and employment arrangements. Paid certifications: Opportunities to earn professional certifications relevant to the role. Tuition reimbursement: Educational support to encourage continued learning and career development. Career advancement: Opportunities to expand clinical utilization management expertise and pursue future professional growth. Incentive opportunities: Bonus and recognition programs may be available, subject to applicable program terms. Remote work: Work from home with the flexibility of a distributed healthcare team, subject to operational requirements. Professional development: Access to training, team collaboration, and continuous improvement initiatives.