Top 6591 Utilization management rn Jobs

Clinical Guide Part A: Utilization Management Nurse
Devoted Health —Remote
- $85,000 - $95,000 a year
- Full-time
- Remote
- RN License
- Mid-level
- 3 years
- Dental insurance
- 401(k)
11d
ISNP Utilization Management Nurse
Longevity Health —Remote
- $81,000 - $99,000 a year
- Full-time
- Nursing
- Clean driving record
- RN License
Quick Apply
11d
Medical Management - Utilization Management RN 145-2026
CommunityCare —Remote
- Full-time
- Remote
- Background check
- Nursing
- RN License
Quick Apply
11d
Medical Management - Utilization Management RN 145-2011
CommunityCare —Remote
- Full-time
- Remote
- Background check
- Nursing
- RN License
Quick Apply
11d
Health Nurse - Utilization Management
Alterwood Health —Remote
- $75,000 - $95,000 a year
- Full-time
- Microsoft Word
- Background check
- Nursing
- Health savings account
- Disability insurance
Quick Apply
13d
Utilization Management Nurse
Brighton Health Plan Solutions, LLC —Remote
- Full-time
- Nursing
- Microsoft Excel
- Microsoft Outlook
Quick Apply
13d
Denials & Appeals Administrator (RN)
Boston Medical Center —Remote
- $43.03 - $62.50 an hour
- Full-time
- Remote
- Nursing
- RN License
- 5 years
- Health insurance
- Dental insurance
Medical Management - Medical Review Examiner Nurse 135-1009
CommunityCare —Remote
- Full-time
- Remote
- Background check
- Nursing
- RN License
Quick Apply
11d
Medical Peer Reviewer
Healthfirst —Remote
- $122,907 - $188,020 a year
- 8 hour shift
- Medicine
- Mid-level
- Communication skills
- Paid holidays
- Health insurance
Utilization Management Nurse
Blue Eagle Consulting —Remote
- RN License
- Mid-level
- Nursing
Quick Apply
Utilization Management Clinical Reviewer
CuraFi —Remote
- $140,000 - $160,000 a year
- Full-time
- RN License
- Senior level
- Communication skills
- Health insurance
- Dental insurance
Quick Apply
13d
Clinical Documentation Specialist
Managed Resources, Inc (MRI) —Remote
- $32 - $45 an hour
- Full-time
- Remote
- Anatomy knowledge
- RN License
- Mid-level
- Paid holidays
- Health insurance
12d
Utilization Review Manager - PRN
Assurance Health System, LLC —Remote
- Part-time
- Remote
- Psychiatry
- RN License
- Mid-level
- Health insurance
- 401(k)
Quick Apply
4d
RN Reviewer
Cohere Health —Remote
- $33 - $35 an hour
- Full-time
- Remote
- Google Workspace
- Nursing
- RN License
- Paid parental leave
- Health savings account
Quick Apply
Sr. Clinical Denials Appeal Specialist (Remote)
Stanford Health Care —Sacramento, CA
- $66.52 - $88.14 an hour
- Full-time
- Remote
- Nursing
- RN License
- Analysis skills
13d
Utilization Review Nurse
Health Business Solutions LLC —Remote
- Remote
- Nursing
- RN License
- Bachelor of Science
13d
Clinical Denials Specialist
Firstsource Healthcare —Remote
- Monday to Friday
- Remote
- RN License
- HIPAA
- Research
- Health insurance
- Dental insurance
Remote Home Health RN – Medical Claims Reviewer
Broadway Ventures —Remote
- $60,000 - $63,000 a year
- Full-time
- Remote
- Nursing
- RN License
- Customer service
- Disability insurance
- Dental insurance
Quick Apply
Clinical Review & Correspondence RN
Cohere Health —Remote
- $31 - $35 an hour
- Full-time
- Remote
- Nursing
- RN License
- Mid-level
- Paid parental leave
- Health savings account
Quick Apply
UMNC
CVS Health —California
- $32.01 - $68.55 an hour
- Weekends as needed
- Remote
- Nursing
- RN License
- Computer literacy
- Health insurance
- Dental insurance

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Clinical Guide Part A: Utilization Management Nurse

Devoted Health -
Remote

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Job Details

Full-time
$85,000 - $95,000 a year
11 days ago

Benefits

Internet reimbursement
Stock options
Dental insurance
401(k)
Paid time off
Parental leave
Vision insurance

Qualifications

Inpatient experience
Medicare
RN License
CMS
CMS regulatory compliance
Medicare regulations
Hospital experience

Full Job Description

Job Description

Schedule:

The weekly schedule choice is either Monday - Friday 10am-7pm EST OR Tuesday - Saturday 9am-6pm EST

A bit about this role:

The Clinical Guide Part A will be part of the Utilization Management team, responsible for inpatient, behavioral health, and/or post-acute authorization review in alignment with CMS and Medicare Advantage regulations.

Reviews medical records to evaluate the medical necessity and appropriateness of requested inpatient and/or post-acute services in accordance with established clinical criteria and CMS guidelines.

Your Responsibilities and Impact will include:

Review Medical Records: Conduct prospective (pre-service), concurrent, and retrospective utilization review to evaluate medical necessity, appropriate level of care (Inpatient vs. Observation), and post-acute services in accordance with established clinical criteria and CMS guidelines.
Evaluate Treatment Plans: Assess the appropriateness, timing, and setting of requested services, ensuring alignment with medical necessity criteria and Medicare Advantage requirements. Recommend alternative levels of care when clinically appropriate.
Inpatient & Behavioral Health Review: Perform initial, concurrent, and discharge reviews for inpatient and behavioral health admissions. Ensure admission status accuracy and regulatory compliance with CMS timeliness (TAT) standards.
Post-Acute Review: Conduct initial authorization and concurrent review for post-acute services (SNF, LTACH, ARU, Home Health), evaluating ongoing medical necessity and appropriate length of stay. Issue NOMNC when coverage criteria are no longer met.
Medical Director Collaboration: Refer cases that do not meet criteria to the Medical Director for secondary review and final determination. Prepare clinical summaries and coordinate peer-to-peer (P2P) discussions. Manage authorization reopen requests as appropriate.
Resource Stewardship: Monitor utilization of inpatient and post-acute services to promote appropriate resource use while maintaining high-quality, member-centered care.
Regulatory & Documentation Compliance: Maintain accurate, defensible documentation of all determinations. Ensure adherence to CMS regulations, Medicare Advantage requirements, and internal compliance standards.

Required skills and experience:

Unrestricted RN license with a minimum of 4 years of clinical experience.
Minimum 3 years of Utilization Management or Inpatient UR experience within a health plan or hospital setting.
Strong knowledge of CMS regulations and Medicare Advantage requirements.
Experience preparing cases for Medical Director review
Able to work in a fast paced environment that is constantly evolving.

Desired skills and experience:

Experience with AI/LLM
Certified in InterQual

#LI-Remote
#LI-DS1

Salary Range: $85,000-$95,000 / year

The pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered will depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job.

Our Total Rewards package includes:

Employer sponsored health, dental and vision plan with low or no premium
Generous paid time off
$100 monthly mobile or internet stipend
Stock options for all employees
Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles
Parental leave program
401K program
And more....

Our total rewards package is for full time employees only. Intern and Contract positions are not eligible.

Founded in 2017, Devoted Health is on a mission to dramatically improve the health and well-being of older Americans by caring for everyone like they are family, and that includes our employees. Our robust and seamlessly integrated care platform merges advanced data and AI access with world-class clinical and service experiences to create a member experience that is unlike the industry norm. To continue building upon our mission, we want to bring together those who share our values, embrace change and advancement, and are enthusiastic about where we're going — all the while bringing their own unique qualities, experiences, and expertise, in hopes of further changing the healthcare experience.

Devoted is an equal opportunity employer. We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in Devoted’s Code of Conduct, our company values and the way we do business.

As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.

We have been made aware of instances of fraudulent job postings and/or fraudulent recruiting activity by individuals purporting to represent Devoted Health. These fraudulent schemes often seek monetary contributions or payments from job seekers (such as for “start up costs” or “equipment”), or seek to collect sensitive personal information. These job postings and offers are NOT authorized by Devoted Health and Devoted is not responsible for fraudulent offers, personal information that you may have disclosed, or payments made to third parties purporting to represent Devoted. We have reported this matter and are cooperating with law enforcement agencies. Devoted Health will never ask for financial commitment or contribution from a candidate at any stage of the recruitment process.

Apply Now

Refine Your Search

utilization management rn jobs

Clinical Guide Part A: Utilization Management Nurse

ISNP Utilization Management Nurse

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Health Nurse - Utilization Management

Utilization Management Nurse

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UMNC

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