Remote Utilization Management Nurse – Inpatient Appeals RN

About the role

We are looking for an experienced Registered Nurse to join our remote team as a Utilization Management Nurse focusing on inpatient appeals. The role involves reviewing denied inpatient cases, creating evidence‑based clinical rationales, and supporting compliant appeal determinations.

Key responsibilities

• Review post‑denial inpatient cases at the appeals level.
• Analyze medical necessity and appropriate level of care using InterQual and/or Milliman criteria.
• Develop clear, evidence‑based clinical rationales for appeal determinations.
• Collaborate with internal teams on escalated and complex cases.
• Ensure compliance with payer policies, regulatory standards, and internal guidelines.
• Maintain a consistent caseload while meeting productivity and quality targets.

Required profile

• Active RN license.
• Minimum 3 years of Utilization Management experience.
• Direct inpatient appeals experience within a payer or health‑plan environment.
• Strong working knowledge of InterQual and/or Milliman guidelines.
• Proven ability to write detailed clinical justifications and appeal outcomes.

Required skills

• InterQual
• Milliman
• Utilization Management
• Inpatient Appeals