Virtual Utilization Review RN

Job Description

Job Description

We are seeking a Registered Nurse to perform hospital utilization reviews, assess medical necessity, and support appropriate levels of care. This remote role partners with physicians, care managers, insurance carriers, and revenue cycle teams to promote quality outcomes, prevent denials, and ensure regulatory compliance.

Overview:

Resource Utilization & Medical Necessity

• Evaluate Care Appropriateness: Conduct medical necessity and level-of-care reviews (including admission, continued stay, and observation) using approved clinical criteria, whether working onsite or remotely.
• Optimize Resource Usage: Utilize proactive indicators (diagnoses, cost criteria, complications) to detect potential over- or under-utilization and address barriers to patient progress.
• Manage Carrier Reviews: Submit required clinical documentation to commercial carriers and the Financial Clearance Center (FCC) within one business day of admission.
• Coordinate Level-of-Care Decisions: Facilitate physician advisor referrals and second-level reviews; collaborate with providers and care managers to secure necessary clinical documentation and clarify status.
• Ensure Age-Specific Care: Assess patient data across all age groups and lifespans using clinical criteria, situational analysis, and departmental guidelines to prioritize reviews.

Revenue Integrity & Denial Management

• Manage Appeals & Peer-to-Peer (P2P): Coordinate the P2P review process alongside physicians, the FCC, and Revenue Cycle teams, maintaining comprehensive documentation for appeal tracking.
• Prevent & Track Denials: Maintain thorough documentation to minimize denial rates, log status updates and overturned days, monitor readmissions, and report emerging denial trends.
• Execute Revenue Workflows: Manage assigned ConnectCare and ADT work queues to ensure seamless billing operations and compliance with CMS and revenue cycle goals.
• Resolve Billing Issues: Partner with Patient Access, Financial Counselors, the FCC, and the Business Office to resolve third-party payer billing concerns and communicate non-coverage determinations.

Communication & Interdisciplinary Collaboration

• Maintain Multidisciplinary Rapport: Partner closely with physicians, in-house care managers, nursing staff, and leadership to align on patient management and outcomes.
• Educate Stakeholders: Train hospital and medical staff on utilization review processes, regulatory updates, and payer requirements (e.g., MS-DRGs, POA).
• Adhere to Communication Protocols: Maintain professional, timely responsiveness across email, phone, and messaging tools according to FCC service-level agreements and guidelines.
• Maintain Professionalism: Exhibit a calm, constructive demeanor during stressful situations or conflict resolution.

Team Engagement & Administrative Responsibilities

• Support Departmental Operations: Assist peers during high-volume periods, cover coverage gaps, and accurately log statistical data within established deadlines.
• Drive Process Improvement: Actively contribute to departmental quality initiatives, committee meetings, task forces, and staff development programs.
• Ensure Compliance: Maintain clinical competency, professional development, and strict adherence to hospital policies, HIPAA, confidentiality standards, and patient rights.
• Flexibility: Perform additional job-related duties as assigned by leadership.

Required Skills:

• Current unrestricted RN license required; RN compact license preferred
• Minimum of 3 years Inpatient Utilization Review experience.
• Clinical nursing experience in ICU, Emergency Department, or Operating Room
• Current working knowledge of quality improvement processes
• This is a remote role which requires access to high speed internet
• Here is the revised job qualifications list, organized for clarity and eliminating overlapping requirements:

Other Requirements:

• Clinical & Operational Judgment: Strong clinical assessment, critical thinking, and problem-solving skills, with a proven ability to identify internal and community resources to drive optimal patient, quality, and financial outcomes.
• Communication & Negotiation: Exceptional written and verbal communication skills with a track record of negotiating effectively across physicians, payers, and multidisciplinary healthcare teams.
• Customer Service Focus: Unwavering commitment to delivering exceptional customer service to all stakeholders.
• Time Management & Prioritization: Ability to organize complex information, prioritize competing tasks, and execute effectively in a fast-paced environment.
• Autonomy & Initiative: Highly resourceful and self-motivated with the ability to work independently.
• Innovation & AI Mindset: Inquisitive and open to leveraging modern technologies, including AI, to streamline workflows, eliminate operational friction, and enhance client/patient experiences.
• Remote & Travel Readiness: Remote position; candidates must be willing and able to travel and work on-site at corporate, client, or temporary locations as business needs dictate.

Preferred Skills:

• 5+ UR Nurse Experience
• Pediatric nursing experience
• Interqual system experience

This role follows a 4x10 schedule , meaning you'll work four 10-hour shifts each week , providing an additional day off during the week. Team members are expected to work every other weekend as part of the regular rotation.

Available shift options include:

• 10:00 a.m. - 8:00 p.m.
• 12:00 p.m. - 10:00 p.m.

Boost your earnings with stacked differential pay in addition to our robust benefits package:

• 10% Weekend Differential for all weekend hours worked.
• 10% Evening Differential for shifts worked between 12:00 p.m. and 10:00 p.m.
• Stackable Premiums: Work an evening shift on a weekend and earn a 20% total differential on top of your base rate.

Salary: $63,100 - $94,650 depending on experience.

For California Applicants:

We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO) , and the California Fair Chance Act (CFCA).

This position is subject to a background check based on its job duties, which may include patient care, working with vulnerable populations, access to financial and confidential information, driving, working with heavy machinery, or working in a warehouse or laboratory environment. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.

\nCompany Description

Here at Medix, we are dedicated to providing workforce solutions to clients throughout multiple industries. We have been named among the Best and Brightest Companies to Work For in the Nation for two consecutive years. Medix has also been ranked as one of the fastest growing companies by Inc. Magazine.

Our commitment to our core purpose of positively impacting 20,000 lives affects not only the way we interact with our clients and talent, but also with our co-workers! The goal is lofty, but it is made attainable through the hard work and dedication of our teams and their willingness to lock arms together. Are you ready to lock arms with us?

Company Description

Here at Medix, we are dedicated to providing workforce solutions to clients throughout multiple industries. We have been named among the Best and Brightest Companies to Work For in the Nation for two consecutive years. Medix has also been ranked as one of the fastest growing companies by Inc. Magazine.\r\n\r\nOur commitment to our core purpose of positively impacting 20,000 lives affects not only the way we interact with our clients and talent, but also with our co-workers! The goal is lofty, but it is made attainable through the hard work and dedication of our teams and their willingness to lock arms together. Are you ready to lock arms with us?