This fully remote RN role focuses on utilization management and medical review, using clinical criteria and plan language to determine medical necessity for procedures and services. The work centers on reviewing cases for members with complex care needs and collaborating with providers to support timely, appropriate decisions. It also includes cross-training across case types, mentoring new reviewers, and helping improve review processes and quality.
Key Responsibilities
- Conduct medical review of utilization management cases using clinical criteria, guidelines, and plan policy language.
- Apply critical thinking and evidence-based practice to authorize services or escalate cases for Medical Director review when needed.
- Coordinate with providers and internal partners to support timely, medically necessary care decisions.
- Monitor, evaluate, and document review cases independently while meeting quality and metric expectations.
- Participate in cross-training across multiple case types to support flexible coverage needs.
- Assist with training, mentoring, and feedback for new nurse reviewers and business partners.
- Recommend and help implement process, audit, and technology improvements to enhance quality and efficiency.
Required
- Active, unrestricted RN license in the state of residence with multistate/compact licensure privileges.
- Ability to obtain licensure in non-compact states as needed.
- Associate's degree in nursing required.
- Minimum 3 years of clinical experience.
- At least 1 year of utilization review management and/or medical management experience.
- Ability to attend mandatory 3-week training with full participation.
Preferred
- BSN.
- Experience interpreting plan language, policies, and benefits to determine medical necessity.
- Experience using MCG Milliman, CPB, or other criteria guidelines.
Benefits & Perks
- 100% remote work.
- Full-time schedule, Monday through Friday.
- Comprehensive benefits package including medical, dental, and vision coverage.
- Paid time off.
- Retirement savings options.
- Wellness programs and other employee resources.
- Eligible for bonus, commission, or short-term incentive program in addition to base pay.