Remote Utilization Management RN – Health Plan Experience Required Prior Authorization | Medical Necessity Review | MCG Guidelines
Must Have Active California RN License
TotalMed is seeking experienced Utilization Management Registered Nurses for a fully remote opportunity supporting a health plan.
This role is ideal for RNs with experience in managed care, payer-side utilization management, prior authorization, and clinical medical necessity reviews.
Candidates must have experience reviewing healthcare services against clinical guidelines and collaborating with providers, facilities, and Medical Directors to support appropriate care decisions.
Summary
At TotalMed, we connect healthcare professionals with rewarding opportunities that allow them to use their expertise while advancing their careers. As a trusted healthcare staffing partner, we provide competitive contract opportunities, dedicated recruiter support, and resources to help you succeed throughout your assignment. This fully remote Utilization Management RN opportunity is a great fit for experienced nurses looking to transition their clinical knowledge into a health plan setting while making an impact through medical necessity reviews, prior authorization decisions, and quality-focused care coordination. If you have experience with health plan UM, managed care, clinical reviews, or prior authorizations, we’d love to connect with you!
Position Details
Title: RN – Utilization Management
Location: Fully Remote (equipment provided)
Schedule: Monday-Friday, 8:00 AM – 5:00 PM
Start Date: ASAP
Contract: 6 months – 1 year (potential extension)
Pay: $45-$52/hr weekly pay + optional health benefits through TotalMed
License Requirement: Active California RN License Required
What We’re Looking For
- Active California RN License required
- Experience in Health Plan Utilization Management / Managed Care
- Strong prior authorization review experience
- Experience reviewing clinical documentation for medical necessity
- Experience applying MCG (Milliman Care Guidelines) or similar clinical criteria
- Knowledge of Medicare, Medi-Cal, Medicaid, and/or Commercial health plans
- Experience collaborating with providers and Medical Directors
Key Responsibilities
- Review inpatient and outpatient service requests for medical necessity
- Complete prior authorization reviews and clinical determinations
- Evaluate clinical documentation utilizing MCG clinical guidelines
- Gather additional clinical information from providers and facilities when needed
- Perform concurrent stay reviews and support appropriate length-of-stay decisions
- Assist with discharge planning and post-acute care coordination when assigned
- Review grievances, appeals, and provider disputes as needed
- Collaborate with Medical Directors and Health Services teams regarding clinical decisions
- Identify opportunities for case management, care coordination, and member support programs
Strong Candidate Backgrounds
✅ Health Plan UM Nurse
✅ Prior Authorization Nurse Reviewer
✅ Clinical Review Nurse
✅ Managed Care RN
✅ Payer-Side Utilization Review Nurse
✅ Insurance UM RN
✅ Medicare/Medi-Cal Utilization Management Nurse
#INDCC
Pay: $46.00 - $52.00 per hour
Benefits:
- 401(k)
- Dental insurance
- Health insurance
- Vision insurance
Application Question(s):
- CAN BE LOCATED ANYWHERE IN US - MUST HAVE ACTIVE CA RN LICENSE
Experience:
- Utilization management: 2 years (Required)
- Prior Authorization: 2 years (Required)
- Medi-Cal: 2 years (Required)
Work Location: Remote
