Utilization Review Nurse RN (Part-Time)

TL;DR

Utilization Review Nurse RN (Part-Time): Provide professional assessments and reviews for the medical necessity of treatment requests and plans with an accent on outpatient pre-certifications, inpatient hospital stays, and post-service reviews. Focus on applying guidelines like MCG and NCCN, processing appeals, and ensuring compliance with productivity and quality standards.

Location: Remote, United States. Current RN license in the United States or U.S. territory required. Standard hours Monday–Friday 8:00 AM–5:00 PM PST; weekend availability required.

Compensation: $30-$38 per hour, depending on location, skills, and experience.

Company

Personalized health platform combining health plan administration, holistic wellbeing solutions, and care navigation to reduce costs and improve health outcomes.

What you will do

• Provide first-level review for outpatient pre-certifications, inpatient stays (including mental health and rehab), and post-service claims for medical necessity.
• Work to the top of RN license, referring complex cases to medical directors or senior consultants.
• Process appeals, complete non-certification letters, and review plan documents for benefit determinations.
• Collaborate with hospital staff for patient discharge planning and referrals to case management programs.
• Document all reviews in software, utilize MCG guidelines and policies, and meet daily productivity, quality, and turnaround times.
• Maintain HIPAA compliance, confidentiality, and pass external audits (URAC, NCQA).

Requirements

• Current RN license in the United States or U.S. territory.
• Associate’s degree or diploma from a nursing program.
• 1+ years of clinical experience.
• Strong technical proficiency, independent work capability, and effective communication for remote environment.
• Ability to meet productivity standards, sit 6-8 hours, and use computer constantly.
• Complete annual training and pass testing (IRRA at 90%+).

Culture & Benefits

• Part-time schedule (minimum 28 hours/week) designed around your availability.
• Access to learning, development, and mentorship opportunities.
• Technology and equipment support.
• Inclusive environment celebrating diversity and collaboration.
• Part-time employees not eligible for health benefits.