Utilization Review Nurse, RN

Job Description

Location: Remote (US-based)

We are seeking a Utilization Review Nurse, RN to support medical necessity review and utilization management activities within a managed care environment. This role is responsible for reviewing clinical cases, applying medical necessity criteria, coordinating with providers, and supporting appropriate levels of care across acute and post-acute settings.

This position is ideal for a clinically experienced RN who enjoys combining strong clinical judgment with managed care knowledge to support quality outcomes, appropriate resource utilization, and effective transitions of care.

Responsibilities:

• Conduct concurrent utilization reviews using InterQual, MCG, or similar criteria for inpatient admissions and observation stays
• Apply medical necessity guidelines to determine appropriate levels of care across acute and post-acute settings
• Communicate with physicians, specialists, and clinical teams to obtain supporting clinical information for continued stay reviews
• Identify cases requiring peer-to-peer review and coordinate with medical directors on adverse determination processes
• Review discharge planning activities and collaborate with case management teams on transitions of care
• Process prior authorizations and continued stay reviews for inpatient and post-acute services
• Conduct retrospective medical record reviews to support denied claims and appeal processes
• Document utilization review determinations and supporting rationale within the care management platform
• Monitor trends related to length of stay, readmissions, and utilization patterns to support quality initiatives
• Maintain compliance with payer policies, regulatory requirements, and internal utilization management standards
• Support collaboration between providers, case managers, and managed care teams to promote timely and appropriate care decisions
• Escalate complex clinical or utilization concerns as needed

Qualifications:

• Active Registered Nurse (RN) license required; compact license strongly preferred
• Bachelor of Science in Nursing (BSN) preferred; Associate degree with equivalent experience considered
• Minimum of 3 years of clinical nursing experience required
• Minimum of 1 year of utilization review, case management, or managed care experience preferred
• Working knowledge of InterQual, MCG, or similar clinical decision support tools required
• Understanding of Medicare, Medicaid, and commercial payer utilization management requirements
• Familiarity with CMS Conditions of Participation, observation status rules, and the 2-midnight rule preferred
• Strong analytical, communication, and clinical documentation review skills
• Ability to work independently in a remote environment while managing productivity expectations

Schedule:

• Full-time, remote position
• Standard business hours
• Standard full-time hours per pay period

Salary Range: The salary range for this position is approximately $78,000 – $102,000 annually ($37.50 – $49.04 per hour), based on experience and qualifications.

Interview Process:

• Selected candidates will participate in a multi-step interview process, including an initial screening with TalentLNX followed by interviews with department leadership.

Equal Opportunity Employer: TalentLNX is committed to equal employment opportunity and a diverse, inclusive workforce. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.