Registered Nurse - Utilization Review

Pay: $45.00 - $51.00 per hour
Job Description
Position Details
Position: RN Utilization Management / Utilization Review
Setting: 100% Remote
Schedule: 5x8-hour days
Hours: 8:00 AM 4:30 PM or 9:00 AM 5:30 PM Pacific Time
Weekend: Every third weekend rotation
Typical Caseload: Approximately 1:40
Equipment: Laptop, keyboard, and mouse provided
Required Qualifications
Active California RN license
Minimum 3 years of acute hospital Care Management/Utilization Management experience
Recent hospital-based Utilization Review experience required
Epic experience required, with recent use within the last 6 12 months
InterQual experience required
Strong Medicare knowledge required
Experience determining medical necessity and appropriate level of care
Important: Health plan or medical group UM experience alone does not meet the requirement. Candidates need acute hospital-based Care Management/UM experience.
Key Responsibilities
Perform concurrent utilization reviews for inpatient, observation, and extended outpatient levels of care.
Review admissions and continued stays for medical necessity using InterQual criteria.
Evaluate clinical documentation to determine appropriate level of care and continued stay.
Complete admission, concurrent, continued stay, and retrospective reviews.
Collaborate with physicians, Case Management, and multidisciplinary teams regarding utilization and medical necessity.
Review patient status and ensure compliance with Medicare and regulatory requirements.
Support care coordination and appropriate utilization of healthcare resources.
Manage prior authorization and pre-certification activities when applicable.
Review clinical information involving ICU, Medical-Surgical, pediatric, and other acute-care populations.
Maintain accurate and timely documentation within Epic.
Support centralized UM operations across three facilities and rotate assignments based on department needs.
Maintain productivity while managing a caseload of approximately 40 reviews/patients.

Work arrangement
Yes