Utilization Review Nurse
Varite Inc
Job Description:
Responsibilities:
Experience:
Skills:
Education:
Questionnaire:
About US Tech Solutions:
US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit
US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
- Participates in the development and ongoing implementation of QM Work Plan activities.
- Improve quality products and services, by using measurement and analysis to process, evaluate and make recommendations to meet QM objectives
Responsibilities:
- Reviews documentation and evaluates Potential Quality of Care issues based on clinical policies and benefit determinations.
- Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation.
- Data gathering requires navigation through multiple system applications.
- Staff may be required to contact the providers of record, vendors, or internal Aetna departments to obtain additional information.
- Evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines.
- Responsible for the review and evaluation of clinical information and documentation.
- Reviews documentation and interprets data obtained form clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider issues.
- Works Potential Quality of Care cases across all lines of business (Commercial and Medicare).
- Independently coordinates the clinical resolution with internal/external clinician support as required.
- Processes and evaluates complex data and information sets -Converts the results of data analysis into meaningful business information and reaches conclusions about the data
- Prepares and completes QM documents based on interpretation and application of business requirements
- Documents QM activities to demonstrate compliance with business, regulatory, and accreditation requirements
- Assists in the development and implementation of QM projects and activities
- Accountable for completing and implementation of QM Work Plan Activities
Experience:
- 3+ years of experience as an RN
- Registered Nurse in state of residence
- Must have prior authorization utilization experience
- Experience with Medcompass
Skills:
- MUST HAVE MEDCOMPASS or ASSURECARE exp.
- MUST HAVE MANAGED CARE exp and Medicare/Medicaid knowledge.
- MUST HAVE UM experience, inpatient utilization management review.
- MUST HAVE 1 YEAR OF UTILIZATION MANAGEMENT EXP, pref. knowledge of Milliman/MCG.
- MUST HAVE 6 months of Prior Authorization.
Education:
- Active and unrestricted RN licensure in state of residence
Questionnaire:
- Do you have experience with Medcompass?
- Do you have experience with Prior Authorization?
- Do you have experience with Utilization Review?
- Do you have an Active Registered Nurse License?
About US Tech Solutions:
US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit
US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
Vacancy posted 20 hours ago
Similar jobs that could be interesting for youBased on the Utilization Review Nurse in United States vacancy
$40.12 - $62.19 per hour
...Utilization Review Nurse RN - Grace Medical Center ~ Baltimore, MD ~GRACE MEDICAL CENTER ~Part-time - Weekends - Day shift - 8:00am-4:30pm ~RN OTHER ~96385 ~$40.12-$62.19 Experience based ~ Posted: April 28, 2026 Apply Now Save Job Saved...SuggestedPart timeShift workWeekend workDay shift- ...City/State Norfolk, VA Work Shift First (Days) Overview: Sentara Health Plansis hiring an Utilization Review Nurse/RN- Remote in Virginia Status: Full-time,permanent position (40 hours) Standard working hours: 8am to 5pm EST, M-F Location: Remote...SuggestedPermanent employmentFull timeTemporary workRemote workShift work
Sentara Health
Norfolk, VA9 hours ago - ...A leading healthcare solutions company is seeking an experienced Utilization Review Nurse to improve patient care through home-based services. Responsibilities include processing authorization requests, ensuring compliance with Medicare guidelines, and collaborating with...SuggestedRemote work
Medix
New York, NY2 days ago $35 - $40 per hour
...Base Pay Range $35.00/hr - $40.00/hr Location Fully Remote Position Summary The Utilization Review Nurse serves as a key liaison in coordinating resources and services to meet patients’ needs, ensuring efficient, cost-effective, and compliant delivery of...SuggestedContract workRemote workFlexible hoursWeekend workIntePros
Phoenix, AZ4 days ago$30 - $38 per hour
...lives. Learn even more about the work that drives us at personifyhealth.com. Responsibilities Job Summary We are seeking Utilization Review Nurse RN to join our team on a part‑time basis, working a minimum of 28 hours per week. The Utilization Review Nurse will provide...SuggestedHourly payFull timePart timeWork at officeRemote workMonday to FridayWeekend workSanta Barbara Cottage Hospital
New York, NY2 days ago$30 - $38 per hour
...A healthcare organization is seeking a part-time Utilization Review Nurse RN to conduct assessments and reviews for medical necessity of treatment requests. This role involves working 28 hours per week with responsibilities such as providing reviews for pre-certification...Hourly payPart timeRemote workSanta Barbara Cottage Hospital
New York, NY2 days ago$18k
...healing ministry within the communities we serve. Our doctors, nurses, and allied health professionals are a regular self-contained... ..., performs criteria-based concurrent and retrospective utilization review to support and encourage the efficient and effective use of resources...Full timePart timeLive outSanta Barbara Cottage Hospital
New York, NY2 days ago- ...An established industry player in healthcare is seeking a dedicated Utilization Review Nurse to join their team. This role involves conducting critical reviews to ensure efficient resource use and high-quality patient care. You will collaborate with clinical staff and...
Santa Barbara Cottage Hospital
New York, NY2 days ago - ...Overview Title: Clinical Review Nurse – Prior Authorization Review Location: Fully Remote (PST Time Zone - WA/OR Resident)... ...Clinical Review Nurse for Prior Authorization Review to join our Utilization Management team. In this role, you will conduct concurrent...Contract workRemote work
SPECTRAFORCE
Washington DC2 days ago $75k
...HealthHelp is looking for a Registered Nurse to perform inpatient utilization reviews, ensure compliance with medical necessity criteria, and actively engage with healthcare teams to improve patient outcomes. This role requires a current RN license, two years of acute...Remote workFlexible hoursHealthHelp
New York, NY2 days ago$30.64 - $45.8 per hour
...The Utilization Review Nurse gathers demographic and clinical information on prospective, concurrent and retrospective in‑patient admissions and out‑patient treatment, certifies the medical necessity and assigns an appropriate length of stay while supporting the goals...Hourly payMinimum wageFull timeWork at officeLocal areaRemote workFlexible hoursSanta Barbara Cottage Hospital
New York, NY2 days ago$35 - $43 per hour
...Base pay range $35.00/hr - $43.00/hr Job Title Clinical Review Nurse – Concurrent Review Location: Remote (California only – must reside... ...The Clinical Review Nurse – Concurrent Review will perform utilization management functions to ensure members receive the right care...Remote workIMCS Group
New York, NY2 days ago- A healthcare provider is seeking a Utilization Review Nurse to coordinate resources and ensure efficient delivery of home health care. This role involves monitoring patient admissions and ongoing care while ensuring adherence to guidelines. The ideal candidate will have...Contract workRemote work
IntePros
Phoenix, AZ4 days ago $38 - $40 per hour
A healthcare provider is looking for a Registered Nurse (RN) for a remote position in Texas. The RN will be responsible for various review activities and care coordination in the insurance or managed care sector. Candidates must have a valid RN license in Texas and at...Hourly payContract workRemote workMadea Home Care Services
Plano, TX1 day ago- ...RN- Utilization Review Nurse Inpatient *Hybrid* Must reside within the New York Tri-State Area - NY, NJ, or CT COME WORK FOR THE LEADING, LOCAL MANAGED CARE COMPANY - VILLAGE CARE! VillageCare is looking for a self-motivated and passionate RN as Utilization...Full timeLocal areaWork from home
VillageCare
New York, NY4 days ago - ...to meet QM objectives Responsibilities: Reviews documentation and evaluates Potential Quality of... ...3+ years of experience as an RN ~ Registered Nurse in state of residence ~ Must have prior authorization utilization experience ~ Experience with Medcompass...Contract work
US Tech Solutions
Chicago, IL7 days ago $1,988 per week
...LeaderStat is seeking a travel nurse RN Case Manager, Utilization Review for a travel nursing job in Santa Rosa, California. Job Description & Requirements ~ Specialty: Utilization Review ~ Discipline: RN ~ Start Date: 06/15/2026 ~ Duration: 13 weeks...Weekly payFull timeContract workInterim roleShift workLeaderStat
Santa Rosa, CA1 day ago$38 - $40 per hour
...responsible for performing initial, concurrent review activities; discharge care coordination... .... Provides information regarding utilization management requirements and operational... ...QUALIFICATIONS (Required) ~ Registered Nurse (RN) with a valid, current, unrestricted...Hourly payContract workWork at officeRemote workMadea Home Care Services
Plano, TX1 day ago- ...quickly as there are multiple programs we utilize—this is a must. Prior UM and/or case... ...would like in this role: Inpatient admission review for hospitals, SNFs, rehab and LTAC facilities... ...software. Education: Associate Degree - Nursing or Graduate of Accredited School of...Contract workWork at officeImmediate startShift work
US Tech Solutions
Columbia, SC9 days ago - ...experience performing care for hospitalized patients 2 years of Utilization Review (UR) experience reviewing hospital admissions for medical... ...in the appropriate setting. Minimum Requirements Education Nursing Diploma/Associate's Nursing Experience 2-5 years Supervisor...Full timeReliefLocal areaRemote workWork from homeMonday to FridayFlexible hoursShift work
BJC HealthCare
Saint Louis, MO4 days ago - ...Utilization Management Review Nurse Harris Health System is the public healthcare safety-net provider established in 1966 to serve the residents of Harris County, Texas. As an essential healthcare system, Harris Health champions better health for the entire community...Work experience placementWork at officeRemote workFlexible hoursWeekend work
Harris Health System
Bellaire, TX1 day ago $57.24k - $62.18k
...Nurses - are you looking for a change? Want to work no nights, no weekends, and no holidays... ...DESCRIPTION: This individual will utilize clinical knowledge and communication skills... ...will defer decision to a second level reviewer. This individual interfaces with case managers...Temporary workWork at officeRemote workWork from homeMonday to FridayFlexible hoursHines and Associates
Rockford, IL2 days ago$40.72 - $63.12 per hour
...Recognized hospital in the state, reflecting UMC's nursing professionalism, teamwork, and superiority in patient care. Position Summary: Reviews patient admissions for appropriateness, efficiency of resource utilization and compliance with third party payer...Hourly payFull timeTemporary workWork experience placementWork at officeAll shiftsShift workWeekend workUniversity Medical Center of Southern Nevada
Deeth, NV1 day ago- ...Providence Health Plan Group is seeking an RN for Utilization Review. This remote position requires strong clinical skills and knowledge in... ...workloads. Ideal candidates have at least an Associate's Degree in Nursing and a California RN License. Providence offers extensive...Daily paidPart timeRemote workShift work
Providence Health Plan Group
Irvine, CA1 day ago - ...Job Title: Utilization Review Nurse Duration : 6 +Months contract + (Possibilities of Extension) Location: 100% Remote (Illinois, Texas, Montana, Oklahoma, New Mexico) Pay: 45.00/- Hr on W2 Duties: Registered Nurse responsible for collaborating with healthcare providers...Contract workWork at officeLocal areaRemote workFlexible hoursShift work
Careers Integrated Resources Inc
New York, NY8 hours ago - ...A community hospital in Arizona is seeking a Utilization Management Nurse to ensure healthcare efficiency and quality through diligent review of medical records and adept communication. You'll engage with multiple stakeholders to uphold clinical decision-making and regulatory...
Santa Barbara Cottage Hospital
New York, NY2 days ago $47.06k - $70.24k
...A healthcare solutions provider is seeking a Utilization Review Nurse in Fort Worth, TX. This remote role involves analyzing medical bill appropriateness, documenting findings, and communicating with claims examiners. Candidates must have a current RN license and at least...Remote workCare Options For Kids
Fort Worth, TX4 days ago- ...Insight Global is looking for a Utilization Review Registered Nurse to sit remotely with one of their large health insurance clients. This person will be responsible for evaluating 3.5 patient care cases per hour (both inpatient and outpatient) and collaborating with doctors...Hourly payRemote work
Insight Global
Raleigh, NC4 days ago - ...Utilization Review Nurse (RN) Neuropsychiatric Hospitals is looking for a Utilization Review Nurse (RN) to coordinate patients' services across the continuum of care by promoting effective utilization, monitoring health resources and elaborating with multidisciplinary...Work at officeRemote work
NeuroPsychiatric Hospitals
United States20 hours ago - ...mission of excellence! JOB SUMMARY The performance of the Utilization Review function on all patients presenting for hospitalization to... ...Experience & License ~ Current unrestricted Wyoming Registered Nurse License. ~ Associates degree in nursing required. Bachelors...Work at officeRelocation packageShift work
Sheridan Memorial Hospital
Sheridan, WY3 days ago
Do you want to receive more vacancies?
Subscribe and receive similar vacancies to Utilization Review Nurse. Be the first to apply!
Related searches
- utilization review nurse work from home United States
- utilization review nurse part time United States
- remote utilization review nurse part time United States
- utilization review registered nurse United States
- remote utilization review nurse United States
- utilization review nurse United States
- utilization review nurse work from home
- utilization review nurse part time
- remote utilization review nurse part time
- utilization review registered nurse