Remote Utilization Review RN Job Description

Introduction: A Clear Path to Impactful Nursing

Step into a nursing career where your clinical insights drive real-time decision-making and make a meaningful impact—all from the comfort of your home. We are seeking a skilled and self-motivated Remote Utilization Review RN who thrives on evaluating patient care, optimizing healthcare resources, and collaborating with multidisciplinary teams. With an annual salary of $87,946, this position offers a flexible work environment where precision meets purpose.

Key Responsibilities: What You Will Do

As a Utilization Review Registered Nurse working remotely, your core role will be reviewing medical documentation, applying evidence-based criteria, and ensuring that patients receive the appropriate level of care. Your attention to detail and clinical judgment will support both patient outcomes and cost-effective services.

• Conduct timely utilization reviews of inpatient, outpatient, and ancillary services.
• Apply InterQual/MCG or other recognized criteria to assess medical necessity.
• Review clinical records for accuracy, consistency, and relevance
• Communicate with physicians, case managers, and other healthcare professionals
• Determine if hospitalization or services are covered under patient benefits
• Escalate complex cases to physician advisors or medical directors when needed
• Document all determinations and rationale within internal review systems
• Participate in peer-to-peer or appeal processes as required
• Comply with organizational guidelines, HIPAA regulations, and URAC standards

Qualifications: What You Bring

This role demands a blend of clinical excellence, critical thinking, and familiarity with healthcare protocols. Your ability to make informed decisions and convey them is key.

• Active, unrestricted RN license in your practicing state (multi-state preferred)
• Minimum of 3 years of acute clinical nursing experience (ICU, med-surg, ER preferred)
• At least 1 year of experience in utilization review, case management, or a related field
• Proficiency with InterQual or MCG guidelines
• Comfortable navigating EMRs and review platforms such as Guideline or TruCare
• Strong analytical skills and decision-making ability
• Excellent verbal and written communication skills
• Able to maintain high productivity independently in a remote setting

Tools & Technology: What You’ll Use

You’ll use digital tools to conduct reviews efficiently and maintain accurate records. Proficiency in these platforms will keep you ahead in this role.

• Electronic Medical Records (EMR) platforms
• Clinical review tools such as InterQual and MCG
• Remote case management systems (e.g., TruCare, Medecision)
• HIPAA-compliant communication channels (secure email, VoIP)
• Internal case tracking software

Work Environment: Structured Yet Flexible

This fully remote role gives you the autonomy to manage your workspace while staying engaged with a supportive team. Expect a results-driven culture that values focus, transparency, and respect.

• Work-from-home position with standard business hours (M-F)
• Occasional flexibility for regional coverage or time zone adjustments
• Regular team huddles and performance syncs via video conferencing
• Digital workflows that eliminate unnecessary administrative burden
• Supportive leadership and clinical escalation pathways

Why This Role Matters: Make Every Review Count

Your work will have a direct impact on how care is delivered across networks. By aligning medical necessity with payer guidelines, you become a steward of clinical appropriateness and resource utilization.

• Reduce unnecessary hospital admissions.
• Support timely and effective patient discharges.
• Strengthen the connection between clinical operations and payer requirements.
• Improve patient satisfaction and outcomes

Growth Opportunities: Advance with Purpose

This role opens doors to broader clinical leadership and healthcare quality roles. As a Utilization Review RN, you’ll gain exposure to:

• Policy development in clinical guidelines
• Auditing and compliance roles
• Clinical education and training programs
• Leadership pathways in population health or care coordination

Benefits & Perks: More Than a Paycheck

Enjoy benefits designed to support your professional and personal growth:

• Competitive annual salary: $87,946
• Health, dental, and vision coverage
• Paid time off, holidays, and sick leave
• Retirement plan with employer contributions
• Continuing education reimbursement
• Equipment stipend for home office setup

Call to Action: Step Into a Role That Elevates Care

If you're ready to bring your nursing expertise to a role that values accuracy, compassion, and clinical rigor, this opportunity is for you. Work where your insights matter, your contributions are valued, and your schedule works for you.

Apply today and redefine what it means to lead in nursing from anywhere.