Remote RN: CMS & NCQA Utilization Management Specialist
GuideWell
GuideWell Mutual Holding Corporation in New York seeks a skilled Registered Nurse (RN) for the Utilization Management Compliance Specialist position. You will apply expertise in compliance, quality reporting, and risk management to ensure adherence to regulatory guidelines. This role involves significant collaboration across departments, requiring a proactive approach to compliance and continuous improvement. Join a company dedicated to transforming health through technology-enabled care. #J-18808-Ljbffr
$77.6k - $126.1k
...highly skilled and experienced Registered Nurse (RN) to join our team as a Utilization Management Compliance Specialist. As a Specialist, you will apply your... ...to Centers for Medicare and Medicaid Services (CMS) and National Quality Care Assessment (NQCA) guidelines...Remote workCmsTemporary workPart timeWork experience placementInternshipSeasonal work$60.2k - $107.4k
...you help us advance health optimization on a global scale.Join us to start Caring. Connecting. Growing together. The Utilization Management RN Coder willaccuratelyandefficientlyreviewandextractpertinentcasedetailsfrompatient medicalrecords;and craft strongly...Remote workCmsMinimum wageFull timeWork experience placementLocal area$60.2k - $107.4k
Job Overview The Utilization Management RN Coder will accurately and efficiently review and extract pertinent case details from patient medical records, craft defensible appeal letters per process instructions, and participate as representatives in tele‑hearings. The role...Remote workCmsMinimum wageFull timeLocal area$116.3k - $264.6k
...Angeles, CA, USA Onsite or Remote Flexible Hybrid... ...at UCLA Health. As a Manager for Medicare Advantage Utilization Management, you'll... ...Current unrestricted RN licensure in CA required... ...Knowledge of Health Plan, DMHC, CMS, HIPPA and NCQA requirements...Remote workCmsMonday to FridayFlexible hours- ...Are you an experienced Registered Nurse (RN) – Utilization Management / Case Management (Medicare) with a desire to excel? If so, then Talent Software... ...On-site training required (1–6 weeks depending on role) Remote/hybrid flexibility available post-training based on...Remote workCmsContract workLocal area
- ...About The Role BHPS provides Utilization Management services to its clients. The... ...coverage while working remotely. Primary Responsibilities... ...• Proficient in MCG and CMS criteria sets • Experience... ...knowledge of URAC and NCQA. • 2+ years’ experience...Remote workCmsContract workWork at officeFlexible hours
- ...Job Summary: The Utilization Management Policy Initiatives Nurse RN II, under the purview the Utilization Management... ...Committee on Quality Assurance (NCQA) Department of Health Care Services... ...Medicare and Medicaid Services (CMS) Model of Care (MOC) through sound...Remote workCms
$34.98 - $42.85 per hour
...Remote in California only Are you ready to make... ...The UM Nurse I - RN performs clinical review... ...policies. This role conducts utilization review activities under... ...Ensure compliance with CMS, state, and contractual... ...1) year in utilization management or case management preferred...Remote workCmsHourly payWork at office$60k
...LVN experienced in the managed care payor environment... ...service and post-service utilization reviews and appeals for... ...and appeals within an NCQA-compliant UM program. Salary... ...such as NCQA, CMS and State agencies Strong... ...development opportunities Remote Opportunities We are...Remote workCmsTemporary workLocal area$26.35 - $39.53 per hour
...Utilization Management Nurse, LVN/LPN California, United States... ...accreditation standards (e.g., NCQA, URAC), and health... ...: Registered Nurse (RN) or Licensed... ...accreditation requirements (e.g., CMS, NCQA, URAC).... ...Corporate office preferred / remote may be considered...Remote workCmsHourly payWork at office$85.7k - $128.54k
The Supervisor, Utilization Management (UM), reports to the Manager of UM and oversees the UM department... ...team and ensuring compliance with CMS regulations. Responsibilities Manage day... ...Licensure: Active, valid, and unrestricted RN or LVN license in California (non‑compact...Remote jobCmsLocal area$72.8k - $130k
...costs while improving risk management, quality and revenue... ...occasional opportunity for remote work based on business needs. As a Sr Utilization Management Nurse in the... ...be a Registered Nurse (RN) with a current, active,... ...industry (Medicaid, Medicare, CMS) ~ Demonstrated...Remote workCmsMinimum wageFull timeWork experience placementCasual workLive inWork at officeLocal area$71.1k - $97.8k
...Solutions is seeking a RN who will collaborate... ...against established CMS Coverage Guidelines/NCQA review criteria and who... ...clinical experience, managed care experience, DME, Florida Medicaid OR utilization management experience... ...: While this is a remote position, occasional...Remote workCmsBi-weekly payFull timeTemporary workApprenticeshipWork at officeWork from homeHome officeWeekend work- ...healthcare solutions company based in Newtown Square is seeking a Utilization Management RN Coder. This role involves reviewing patient medical records... ..., and an unrestricted RN license. The position supports remote flexibility, ensuring compliance with healthcare...Remote job
$84.78k - $131.41k
Department/Unit: Care Management/Social Work Work Shift: Day (United States... ...Under direction of the Manager of Utilization Management, the Utilization Management Specialist is responsible for the... ...knowledge of how to research changes in CMS and payor regulations and project...CmsFull timeWork at officeShift work- ...hospitals) looking for a System Nurse Director Utilization Management! Full Relocation! EPIC Electronic... ...system. Qualifications: ~ Active RN license ~ Certification in Case... ...Strong knowledge of payer requirements, CMS regulations, and accreditation standards...Remote workCmsRelocation
- ...Primary Responsibilities The Utilization Management Nurse will determine the... ...and maintain compliance with CMS requirements, may include after... ...This position is remote but requires the employee to... ...Current unencumbered LVN or RN license in Texas or compact license...Remote workCmsWork at officeWeekend work
- ...Duties • Performs audits in utilization management, care management, member... ...Medicare and Medicaid Services (CMS), and state/federal... ...experience. • Registered Nurse (RN). License must be active and... ...Mexico Turquoise Care Contract, NCQA (National Committee for Quality...Remote workCmsContract workWork at office
$105k - $110k
Job Purpose The Specialist - Quality Management RN works in conjunction with operational and clinical staff... ...standards of care. Job Responsibilities Utilize quality improvement methodologies,... ...(State and Federal agencies, CMS, NCQA, etc.). Collect, summarize, and analyze...CmsWork experience placementWork at office- ...Work remote and travel 75% Optum is a global organization that delivers... ...Optum, UHC, or UBH (e.g. Case Managers, Field Care Advocates) to... ...Current unrestricted RN nurse license in Massachusetts... ...industry (Medicaid, Medicare, CMS) Demonstrated knowledge of...Remote workCmsCasual workWork at office
- ...elevate outcomes, and love your Mondays as the Nurse Director Utilization Review and Case Management at an award winning hospital in the Bay Area—where your... ..., AI-assisted decision support, virtual nursing, and remote monitoring; clear investment in clinician well-being...Remote workCmsWeekend work
$50.68 per hour
...Job Job Overview The Utilization Review RN participates as a member of... ...Department Name: Utilization Management Job Status: flex, not... ...position will be primarily remote but there may be occasions when... ...regulatory requirements, including CMS and Joint Commission...Remote workCmsHourly payTemporary workLive inImmediate startRelocationFlexible hoursShift workWeekend workDay shiftAfternoon shift- ...Epic Tapestry Utilization Management Analyst Location: Eden Prairie, MN (Remote) Position: Contract (05-25-2026 - 09-30-2026) Rate: DOE Role... ...payer operations and UM regulations (e.g., CMS timelines, state TATs, HIPAA, NCQA), including denial and appeal pathways....Remote workCmsContract work
$35 - $45 per hour
...Registered Nurse (RN) | Utilization Review Location: Corpus Christi, TX Agency: Mindlance... ...and Description of Project: Managing a case load for healthcare members with... ...member contact and will include 80% travel. Remote role. Will require a driver’s license....Remote workCmsHourly payFull timeContract workImmediate startShift work3 days per week$40.39 - $60.96 per hour
...Select Health Care Manager Select Health is a community health... ...regulatory requirements such as NCQA, CMS and State EQRO standards.... ...closely related field including Utilization Management, discharge... ...working successfully g in a remote environment or using Advanced...Remote workCmsContract workFlexible hours$31 - $35 per hour
...Clinical Review & Correspondence RN The Clinical Review &... ...critical role in supporting utilization management operations by conducting... ...experience required Knowledge of NCQA and CMS standards and requirements... ...role: This is a 100% remote role, and requires robust...Remote workCmsFull timeFlexible hoursShift work$116.3k - $264.6k
...Utilization Management Assistant Director – RN Location: Los Angeles, CA Salary Range: $116,300 – $264,600 annually Work Hours: Monday – Friday, 8:00am... ...department tracking initiatives Ensure compliance with CMS, NCQA, and organizational policies related to utilization management...CmsMonday to Friday$44.42 - $61.2 per hour
...Registered Nurse (RN) – Care Management Founded in 197... ...will work in the remote & in the field in... ...care providers, specialists, hospitals, skilled... ...Services (CMS), Department of Managed... ...Hospital Or ED Utilization, Adults Living In... ...understanding of NCQA standards, CMS and...Remote workCmsHourly payLocal area- ...preventative care to managing chronic conditions,... .... Position Title Utilization Review Nurse Department... ...Time) Location Remote position Salary Wage... ...(OAR, ORS, CFR, CMS, DMAP). Serve as a... ...Registered Nurse (RN), BSN (Bachelor of... ...working knowledge of NCQA standards, Oregon Health...Remote workCmsFull timeWork at officeLocal areaMonday to FridayFlexible hours
$35 - $45 per hour
...Registered Nurse (RN) | Utilization Review Location: Corpus Christi, TX Agency: Mindlance... ...and Description of Project: Managing a case load for healthcare members with... ...member contact and will include 80% travel. Remote role. Will require a driver’s license....Remote workCmsHourly payFull timeContract workImmediate startShift work3 days per week
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