Lead Utilization Review-RN (Healthcare)

TL;DR

Lead Utilization Review-RN (Healthcare): Providing clinical and operational leadership for utilization management teams with an accent on evidence-based coverage determinations and quality oversight. Focus on coaching reviewers, ensuring regulatory compliance, and optimizing clinical workflows to improve member and provider experiences.

Location: Remote (United States). Must be available to work during PST hours.

Salary: $38–$43 per hour.

Company

A personalized health platform serving employers and health systems with data-driven solutions to reduce costs and improve health outcomes.

What you will do

• Provide clinical and operational leadership to the Utilization Management team.
• Coach reviewers on medical-necessity criteria, medical policy, and benefit plan language.
• Monitor daily workflow health, including intake volume and turnaround risks.
• Review documentation for completeness, audit readiness, and clinical rationale.
• Partner with internal teams and providers to resolve barriers to timely determinations.
• Support onboarding and skill development for clinical staff.

Requirements

• Active RN Licensure required (California license preferred).
• 5+ years of combined clinical experience required.
• 2+ years of utilization review experience required.
• Prior supervisory experience in utilization review or case management.
• Proficiency in medical coding (ICD-10, CPT, HCPCS).
• Must be available to work during PST hours.

Culture & Benefits

• Competitive base salary and benefits package effective from day one.
• Comprehensive medical and dental coverage.
• Paid Time Off for rest and recharge.
• Mental health support and retirement planning.
• Professional development opportunities with learning budgets.
• Mission-driven culture focused on improving health outcomes.