Remote Utilization Review Nurse (Contract)

About the role

The Utilization Review Nurse will work remotely to collaborate with healthcare providers, members, and business partners. The focus is on evaluating medical necessity, optimizing member benefits, and ensuring appropriate use of resources across a range of services.

Key responsibilities

• Review inpatient and outpatient medical services for medical necessity and appropriate setting according to policy and compliance guidelines.
• Apply established criteria to evaluate and authorize services, including drugs, biologics, procedures, home health, DME, and out‑of‑network care.
• Provide timely notification of decisions and coordinate with Medical Directors when additional review is required.
• Participate in staff meetings, trainings, and collaborative sessions as needed.

Required profile

• Current unrestricted RN license (multi‑state license preferred).
• Bachelor’s degree in nursing or a related health‑care field preferred.
• 2‑3 years of clinical experience, with at least 2 years in a regulated environment.
• Strong customer orientation and excellent organizational, planning, and communication abilities.

Required skills

• Medical coding knowledge (CPT, HCPCS, ICD‑10).
• Familiarity with insurance claims processes.
• Understanding of National and Local Coverage Determinations and MCG criteria.

What we offer

• Competitive hourly rate of $41.45 (W2).
• Remote work across IL, TX, NM, MT, or OK.
• 6+ month contract with possible extension.