Utilization Review RN – Remote (US)

About the role

The organization is seeking a Registered Nurse to perform Utilization Management activities on a remote basis across several U.S. states. You will review inpatient and outpatient services for medical necessity, ensure compliance with policies, and help optimize member benefits while collaborating with providers and internal teams.

Key responsibilities

• Review and authorize medical services using established utilization criteria.
• Ensure compliance with medical policies, eligibility rules, and regulatory guidelines such as Medicare and HIPAA.
• Communicate decisions and coordinate with Medical Directors as needed.
• Meet productivity, quality, and turnaround‑time standards.
• Participate in trainings, meetings, and team support activities.

Required profile

• Active, unrestricted RN license (multi‑state preferred).
• 2–3 years of clinical nursing experience; utilization management experience is a plus.
• Knowledge of Medicare, HIPAA, NCQA, and medical necessity criteria (MCG preferred).
• Familiarity with CPT/ICD‑10 coding and the claims process.

Required skills

• CPT coding
• ICD‑10 coding
• MCG utilization criteria