Clinical Review Nurse (Utilization Review) – Remote

About the role

This remote position focuses on reviewing members' medical information to confirm appropriate care levels and compliance with medical necessity guidelines. The nurse translates clinical decisions into clear denial letters that meet NCQA and state regulations while supporting discharge planning and collaborating with care teams.

Key responsibilities

• Perform concurrent reviews to assess level of care, medical necessity, and overall member health status.
• Evaluate acuity, resource utilization, length of stay, and discharge planning to ensure quality and continuity of care.
• Document all findings, actions, and discharge plans in health management systems.
• Convert clinical advisor or medical director decisions into accurate, easy‑to‑understand denial letters.
• Ensure all correspondence complies with NCQA, state, and regulatory standards.
• Collaborate with Medical Directors, Medical Affairs, and care teams for additional clinical clarification.
• Approve or recommend determinations based on requested services and review outcomes.
• Provide education to providers about utilization review processes and requirements.
• Identify trends and give feedback to leadership to improve policies and level‑of‑care alignment.
• Review member transfers or discharge plans to support safe transitions.
• Partner with Care Management teams for appropriate member referrals.
• Maintain high production and quality metrics in a deadline‑driven remote environment.
• Participate in occasional overtime and rotating holiday schedules as needed.

Required profile

• Active Compact Nursing License.
• Minimum 2 years of nursing experience.
• Utilization Management or managed‑care background preferred.

Required skills

• Knowledge of NCQA, state, and regulatory standards for utilization review.
• Proficiency in documenting findings within health management systems.
• Strong written communication to translate clinical decisions into denial letters.