Registered Nurse - Utilization Review

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.