Utilization Review Nurse {167271}

Location: 100% Remote in California
Schedule: Monday-Friday, 8:00 AM-5:00 PM
Pay: $66/hr

We are hiring a Clinical Review Nurse for a remote California-based opportunity focused on appeals, grievances, medical necessity review, and utilization management . This Clinical Review Nurse role is ideal for an RN with strong experience reviewing complex medical records, applying clinical guidelines, supporting accurate reimbursement decisions, and ensuring regulatory compliance in a managed care or health plan environment. If you have a background in utilization review, payment integrity, case management, InterQual, MCG, DRG validation, retrospective review, and appeals/grievances , this Clinical Review Nurse opportunity offers a strong match.

• Conduct clinical review of appeals, grievances, and disputed cases involving medical necessity and level of care
• Review prospective, concurrent, inpatient, and retrospective medical records
• Apply clinical guidelines, policy, procedures, and Evidence of Coverage benefit criteria
• Evaluate denied services and prepare recommendations to uphold or overturn determinations
• Summarize complex medical information for Medical Director and external reviewer consideration
• Document clinical findings, bill audit results, and case activity in tracking systems and databases
• Identify potential quality-of-care concerns , process gaps, and service issues
• Generate written correspondence for providers, members, and regulatory entities
• Support timely case resolution in compliance with state, federal, CMS, NCQA, and managed care requirements
• Collaborate with interdisciplinary teams to improve outcomes, accuracy, and operational efficiency

• Active, unrestricted California RN license
• Minimum 3 years of acute care clinical experience
• Minimum 2 years of appeals and grievances casework
• Strong experience in utilization review, utilization management, quality management, or payment integrity
• Experience with medical necessity review, retrospective claims review, prior authorization, denial review, or provider disputes
• Working knowledge of InterQual, MCG, Medicare, Medi-Cal, managed care, NCQA, DRG validation, and regulatory compliance
• Strong chart review, clinical auditing, documentation, and written communication skills
• Comfortable working independently in a remote, high-volume clinical review environment

If you are a Clinical Review Nurse with experience in appeals, grievances, utilization review, medical necessity, InterQual, MCG, case management, and managed care , apply today.

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