Utilization Management Nurse

We are seeking a skilled, detail-oriented, and clinically knowledgeable Utilization Management Nurse to support medical necessity review, utilization review, care coordination, and quality-focused decision-making in a fully remote environment.

This role is ideal for a nurse who is comfortable reviewing clinical documentation, applying established review criteria, communicating with healthcare professionals, and helping ensure that care is appropriate, efficient, compliant, and aligned with patient needs.

The Utilization Management Nurse will review medical records and clinical information, evaluate the appropriateness of requested or delivered services, collaborate with providers and internal teams, and support the effective use of healthcare resources while maintaining a strong focus on patient outcomes, quality standards, and regulatory compliance.

Key Responsibilities
Review clinical information, medical records, treatment plans, and supporting documentation to evaluate medical necessity and appropriateness of care.
Apply established utilization review criteria, clinical guidelines, payer requirements, and organizational policies when conducting reviews.
Conduct prospective, concurrent, and retrospective utilization reviews as needed.
Assess requested services, procedures, admissions, continued stays, discharges, and levels of care for alignment with clinical standards.
Collaborate with providers, case managers, care coordinators, claims teams, quality teams, and other healthcare professionals.
Document review findings clearly, accurately, and in accordance with organizational and regulatory requirements.
Support care coordination efforts by identifying gaps, delays, barriers, or opportunities for more appropriate levels of care.
Communicate review outcomes, requests for additional information, and escalation needs in a timely and professional manner.
Monitor utilization patterns, trends, and potential areas for improvement.
Participate in quality improvement initiatives, process reviews, audits, and compliance activities.
Maintain confidentiality of patient information and follow HIPAA, payer, regulatory, and organizational requirements.
Support consistent, fair, and evidence-based decision-making across utilization management processes.
Qualifications
Active RN license required.
Associate degree in Nursing required.
Clinical nursing experience required.
Experience in utilization management, utilization review, case management, care coordination, discharge planning, managed care, or payer-based review preferred.
Strong understanding of medical necessity review, clinical documentation, patient care standards, and healthcare workflows.
Ability to interpret clinical information and apply review criteria accurately.
Strong written and verbal communication skills.
Excellent attention to detail and documentation accuracy.
Comfortable working independently in a fully remote environment.
Ability to manage multiple reviews, deadlines, and priorities.
Familiarity with HIPAA, healthcare compliance requirements, and confidentiality standards.
Preferred Experience
Experience using utilization review criteria such as InterQual, MCG, payer guidelines, or similar clinical review tools.
Background in acute care, managed care, insurance, hospital utilization review, case management, or population health.
Experience conducting prior authorization, concurrent review, continued stay review, discharge review, or retrospective review.
Familiarity with electronic medical records, care management platforms, claims systems, or utilization management software.
Certification such as CCM, ACM, CPHQ, or related credential is a plus but not required.
Ideal Candidate

The ideal candidate is a careful and analytical nurse who can review clinical information thoroughly, make sound recommendations, and communicate clearly with providers and internal teams. This person is organized, professional, comfortable with clinical guidelines, and committed to supporting appropriate care, patient outcomes, and responsible use of healthcare resources.

Work Environment

This is a full-time, fully remote position. The Utilization Management Nurse will work from a home-based setting and use electronic systems, virtual communication tools, and clinical review platforms to complete reviews, document findings, and collaborate with healthcare teams.

Compensation

Salary Range: $110,000–$130,000 annually, depending on experience, licensure, education, certifications, and qualifications.

Benefits
Fully remote work environment
Competitive salary
Health, dental, and vision insurance
Paid time off and paid holidays
Retirement plan options
Professional development support
Opportunity to support quality care and effective healthcare resource management
Equal Opportunity Statement

We are an equal opportunity employer and welcome applicants from diverse backgrounds. All qualified candidates will receive consideration without regard to race, color, religion, sex, national origin, disability, veteran status, age, or any other protected status under applicable law.