Utilization Review Nurse (Healthcare)

TL;DR

Utilization Review Nurse (Healthcare): Assessing medical appropriateness and necessity for pre-certification and inpatient requests with an accent on evidence-based clinical guidelines. Focus on evaluating medical necessity, managing appeals, and coordinating patient transitions to ensure efficient care delivery.

Location: Remote (Must be based in the United States)

Salary: $25.00–$31.00 per hour

Company

A personalized health platform integrating health plan administration, holistic wellbeing solutions, and comprehensive care navigation.

What you will do

• Assess outpatient, ancillary, and inpatient pre-certification requests for medical appropriateness and necessity.
• Evaluate post-claim and post-service requests against clinical guidelines to confirm medical necessity.
• Coordinate patient discharges and smooth transitions to the next level of care.
• Process appeals for non-certified services and complete non-certification letters accurately.
• Refer cases to case management, wellness, and chronic disease programs based on clinical needs.
• Maintain accurate and timely documentation in utilization management systems using MCG, NCCN, and Medscape.

Requirements

• Current LVN license in the United States or a U.S. territory.
• 1+ years of clinical experience.
• Working knowledge of medical claims and ICD-10, CPT, and HCPCS coding.
• Proficiency with Microsoft Word, Excel, PowerPoint, and Outlook.
• Familiarity with MCG guidelines, NCCN criteria, and Medscape.
• Experience documenting reviews in utilization management systems (e.g., Eldorado/Episodes).

Culture & Benefits

• Comprehensive medical and dental benefits effective from day one.
• Paid Time Off for rest and recharge.
• Mental health support, retirement planning, and financial protection.
• Professional development with clear career progression and learning budgets.
• Mission-driven culture committed to diversity, equity, and inclusion.