Conduct concurrent utilization reviews for inpatient, observation, and extended outpatient care, with a focus on medical necessity, level of care determinations, and continued stay reviews. Work with acute-care populations across ICU, medical-surgical, pediatric, and other hospital settings while reviewing documentation, admissions, and retrospective cases. This fully remote role supports centralized utilization management across multiple facilities and uses Epic and InterQual in a Medicare-focused review workflow.
Key Responsibilities
- Conduct concurrent, admission, continued stay, and retrospective utilization reviews.
- Review clinical documentation to determine medical necessity and appropriate level of care.
- Use InterQual criteria to evaluate inpatient, observation, and extended outpatient stays.
- Collaborate with physicians, Case Management, and multidisciplinary teams on utilization decisions.
- Maintain accurate and timely documentation in Epic.
- Support prior authorization and pre-certification activities when applicable.
- Review cases involving ICU, medical-surgical, pediatric, and other acute-care patients.
- Coordinate care utilization and compliance with Medicare and regulatory requirements.
Required
- Active California RN license.
- At least 3 years of acute hospital Care Management or Utilization Management experience.
- Recent hospital-based Utilization Review experience.
- Recent Epic experience within the last 6 to 12 months.
- InterQual experience.
- Strong Medicare knowledge and experience determining medical necessity and level of care.
Benefits & Perks
- Fully remote work.
- Hourly pay of $45.00 to $51.00.
- Laptop, keyboard, and mouse provided.
- Scheduled weekday shifts with every third weekend rotation.