REMOTE Utilization RN - 235674

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About the Role

We are seeking a highly skilled, self-motivated, and critical-thinking Utilization Review (UR) Nurse Specialist to join our team. In this fully remote position, you will play a key role in resource management, care appropriateness, and revenue integrity. You will be responsible for evaluating medical necessity, managing level-of-care decisions, minimizing denial rates, and collaborating closely with physicians, interdisciplinary teams, and commercial carriers.

If you are an experienced RN with acute care background (ICU, ED, OR), exceptional clinical judgment, and an interest in leveraging modern technology and AI to streamline workflows, we want to hear from you!

Key Responsibilities

• Evaluate Care Appropriateness: Conduct medical necessity and level-of-care reviews (admission, continued stay, observation) using approved clinical criteria 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.

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.

Work Schedule & Shifts

This position operates on a 4x10 schedule (four 10‑hour shifts per week), giving you an extra day off every week .

• Weekend Rotation: Team members work every other weekend as part of the regular rotation.
• Shift Options Available:
• 10:00 a.m. – 8:00 p.m.
• 12:00 p.m. – 10:00 p.m. (Primary focus)
• Base Salary: Midpoint around $78,875/year (up to $90,000–$92,000/year for highly experienced UR candidates).
• 10% Weekend Differential: Applied to all weekend hours worked.
• 10% Evening Differential: Applied to shifts worked between 12:00 p.m. and 10:00 p.m.
• 20% Stacked Premium: Combine evening and weekend shifts to earn a total 20% differential on top of your base pay!

Qualifications & Requirements

Required Skills & Qualifications

• Licensure: Current unrestricted Registered Nurse (RN) license required (RN Compact license preferred).
• Clinical Experience: Hands-on clinical nursing experience in ICU, Emergency Department (ED), or Operating Room (OR).
• Quality Improvement: Working knowledge of healthcare quality improvement processes.
• Remote Setup: High-speed internet access suitable for remote work.
• Clinical & Operational Judgment: Strong clinical assessment, critical thinking, and problem-solving skills with a proven ability 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.
• Time Management & Prioritization: Ability to organize complex information, prioritize competing tasks, and execute effectively in a fast-paced environment.
• Autonomy & Initiative: Highly resourceful, self-motivated, and able to work independently.
• Innovation & AI Mindset: Inquisitive and open to leveraging modern technologies, including AI, to streamline workflows and eliminate operational friction.
• 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 & Experience

• 5+ years of dedicated Utilization Review (UR) Nurse experience.
• Pediatric nursing experience.
• Hands-on experience with the InterQual system.