Utilization Review RN (Remote, US)

About the role

We are seeking a Registered Nurse to join our Utilization Management team on a remote basis across several states. The Utilization Review RN will evaluate inpatient and outpatient services for medical necessity, ensure compliance with policies, and help optimize member benefits.

Key responsibilities

• Review and authorize medical services using established criteria and guidelines.
• Ensure compliance with medical policies, eligibility rules, and regulatory standards such as Medicare, HIPAA, and NCQA.
• Communicate decisions and coordinate with Medical Directors and providers as needed.
• Meet productivity, quality, and turnaround‑time targets.
• 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.
• Familiarity with Medicare, HIPAA, NCQA, and medical necessity criteria (MCG preferred).
• Strong communication, organization, and time‑management abilities.

Required skills

• CPT coding.
• ICD‑10 coding.
• Claims processing knowledge.
• MCG clinical criteria.