The Utilization Management Review Nurse will conduct reviews for hospitalizations, post-acute admissions, prior authorizations, and appeals, using national standard guidelines to determine if the clinical information meets criteria. This role involves working collaboratively with medical directors and case managers, assessing and planning healthcare services for members, and communicating with providers to facilitate care. The position is full-time, remote, and requires strong organizational, communication, and multitasking skills.

Utilization Management Review Nurse

The Utilization Review Nurse is responsible for reviewing Workers Compensation requests submitted by providers, requestors, claimants, or carriers to determine the medical necessity of the treatment. This role involves utilizing clinical expertise and evidence-based treatment guidelines, performing evaluations of medical data, and coordinating information between all parties involved. The position is remote but requires living in the state of Florida.

Utilization Review Nurse (Injured Workers)

Utilization Review Nurse

The Utilization Review Nurse is responsible for the review of precertification admission and concurrent reviews for the appropriateness of the inpatient setting utilizing InterQual criteria. This role involves entering or referencing data via PC, collaborating with facilities, providers, and Medical Directors, and requires excellent written and oral communication skills. The position is remote, with a work location in Detroit, MI, and is a 10-month contract job type.

As a Utilization Review RN at Ascension Seton Northwest, you will provide healthcare services related to admissions, case management, discharge planning, and utilization review. This role involves reviewing admissions and service requests for medical necessity and compliance with reimbursement policy criteria, providing case management and consultation for complex cases, assisting with coding, medical records, precertification, reimbursement, and claim denials/appeals, and overseeing compliance to utilization management rules and regulations.

Utilization Review RN - Utilization Review

Utilization Review RN

The Case Management Utilization Review Registered Nurse at Steward Health Care is responsible for documenting medical necessity for inpatient status or placement in observation, communicating with physicians and clinicians, and ensuring timely clinical information is sent to payors for authorization. This role involves coordinating with allied health professionals to ensure quality care and outcomes, developing physician profiles for utilization patterns, and optimizing inpatient length of stay and resource utilization.

Case Management Utilization Review RN - REMOTE - Utilization Review

Case Management Utilization Review Registered Nurse

The Utilization Management Nurse Reviewer (RN) serves as the Subject Matter Expert for patient admission status (inpatient and observation) at Wooster Community Hospital. This role involves working with Providers, Case Management, and the Revenue Cycle team to ensure appropriate admission status, protecting the financial interests of the organization by ensuring the UM review cycle is successfully completed, and tracking and trending payer issues. The position is remote but must be within a 4-hour drive of the hospital.

Utilization Management Nurse Reviewer - FT

Utilization Management Nurse Reviewer

A large healthcare insurance company local to the Philadelphia area is seeking a fully remote Case Management RN to join their Care management team. The role involves telephonic or onsite review of hospital admissions, determining alternative settings when appropriate, promoting efficient and high-quality use of the healthcare delivery system, and facilitating timely and dynamic discharge planning. The RN will collaborate with the hospital utilization review department, attending physicians, and members/families as appropriate.

Utilization Management RN - REMOTE (PA, NJ, DE)

Utilization Management Registered Nurse

Cambia Health Solutions, Inc is seeking a Care Management Nurse to join their team, offering a work from home opportunity within Oregon, Washington, Idaho, or Utah. This role involves providing clinical care management, including case management, disease management, and care coordination, to meet members' healthcare needs and promote quality and cost-effective outcomes. The position is part of a candidate pool for future opportunities, allowing candidates to be considered for all suitable positions as they become available.

Remote Care Management Nurse (Future Opportunities)

Care Management Nurse

The Registered Nurse - Utilization Review at Ascension St. Vincent's Birmingham is responsible for providing health care services regarding admissions, case management, discharge planning, and utilization review. This role involves reviewing admissions and service requests for medical necessity, providing case management for complex cases, assisting staff with coding, documentation, and reimbursement issues, and overseeing compliance with utilization management rules. The position requires at least 3 years of acute care experience and utilization management experience.

Registered Nurse RN - Utilization Review  PRN

Registered Nurse - Utilization Review

Pine Park Health is seeking a Registered Nurse to join their team, focusing on providing primary care to residents of senior living communities. The role involves collaborating with a multidisciplinary team, triaging communications, supporting care team members, engaging in comprehensive chart preparation, overseeing post-appointment processes, conducting virtual patient assessments, and participating in quality improvement initiatives. The ideal candidate will have at least 2 years of clinical experience, preferably in geriatrics, and strong experience in remote roles.

Registered Nurse - Remote - Med Surg

Registered Nurse - Med Surg

AmeriHealth Caritas is seeking a Care Manager II Registered Nurse for their Foster Care Program in South Carolina. This remote position requires a BSN and an unrestricted RN license in South Carolina or a compact state. The role involves engaging directly with members through face-to-face visits in the community, monitoring and updating care plans, and collaborating with healthcare professionals to ensure members receive comprehensive care. The ideal candidate will have experience in pediatric home care or acute care, and preferably in the Foster Care System, Department of Social Services, or Department of Juvenile Justice.

REMOTE | CARE MANAGER II REGISTERED NURSE (BSN) - FOSTER CARE PROGRAM -SC

Care Manager II Registered Nurse

The Utilization Management Clinician I performs utilization review for medical or behavioral health requests using established criteria, technologies, and tools. This role involves identifying, coordinating, and implementing high-quality, cost-effective alternatives for patient care, supporting physician decision-making, and ensuring timely access to care during transitions. The position is fully remote and available across Washington, Oregon, Idaho, Texas, and Florida.

Utilization Management Clinician I - RN or LPN

The Registered Nurse - Review Analyst at W3R Consulting will perform prospective, concurrent, and retrospective review of inpatient, outpatient, ambulatory, and ancillary services to ensure medical necessity, appropriate length of stay, intensity of service, and level of care, including appeal requests initiated by providers, facilities, and members. This role may also involve establishing care plans and coordinating care through the healthcare continuum, including member outreach assessments.

Registered Nurse

Registered Nurse - Review Analyst

The Nurse Manager at WellGuide Health will manage the utilization management team and case management team, including prior authorization, utilization review, appeals, and case management. This role involves close collaboration with the director of clinical operations and focuses on enforcing policies, conducting chart audits, monitoring productivity, and addressing staffing and training needs. This is a full-time remote position that may require working evenings, weekends, and holidays.

Nurse Manager

As a Quality Management Nurse Consultant at CVS Health, you will be responsible for the review and evaluation of clinical information and documentation. This role involves interpreting data from clinical records or systems, applying clinical criteria and policies in line with regulatory and accreditation requirements, and coordinating clinical resolution. The position is full-time, remote, and requires adherence to company policies regarding confidentiality.

Quality Management Nurse Consultant

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