Top 6 Utilization management nurse Jobs in Hamilton, Tx

Claims Nurse (Utilization Management / Claims Review) Must have CALIFORNIA license
Dragonfly Global —United States
- $100,000 - $105,000 a year
- Full-time
- Remote
- LVN
- RN License
- Mid-level
- Travel reimbursement
- Health savings account
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Claims Nurse (Utilization Management / Claims Review) Must have CALIFORNIA license
Dragonfly Global —United States
Location:* Remote (California RN or LVN license required). Active, unrestricted *RN or LVN/LPN license in California*. Work remotely with a high-impact team.
$100,000 - $105,000 a year
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Claims Nurse (Utilization Management / Claims Review) Must have CALIFORNIA license

Dragonfly Global
United States

Quick Apply

Job Details

Full-time
$100,000 - $105,000 a year

Benefits

Travel reimbursement
Health savings account
Disability insurance
Health insurance
Dental insurance
Flexible spending account
Paid time off
Parental leave
Employee assistance program
Vision insurance
401(k) matching
Employee discount
Professional development assistance
Flexible schedule
Life insurance
Referral program
Retirement plan

Qualifications

Collaborate with healthcare professionals
Teamwork
Medicare
Utilization review
Medical claims processing software
CMS regulatory compliance
Retrospective medical coding audits
Medicare regulations
Utilization management
Attention to detail
Resource utilization in healthcare
Centers for Medicare & Medicaid Services (CMS) billing regulations
LPN
Milliman Care Guidelines (MCG Health)
Healthcare claims compliance audits
Documentation review
Cross-functional communication
Documentation reviews
Nursing

Full Job Description

Registered Nurse RN or LVN– Retrospective Claims Review

Location: Remote (California RN or LVN license required)
Employment Type: Contract to permanent hire.

Schedule: Mon-Friday 8am-5pm Pacific Standard Time
Compensation: $100,000-$105,000 annually

About the Opportunity

We are partnering with a leading healthcare organization to identify a skilled Claims Review Nurse with deep experience in retrospective medical claims analysis. This role is ideal for a clinically strong nurse who understands how to evaluate services after they’ve been rendered, ensuring accuracy, compliance, and appropriate reimbursement.

This position plays a critical role in identifying discrepancies, preventing improper payments, and supporting high-quality, cost-effective care through detailed post-service review.

Key Responsibilities

Conduct retrospective review of medical claims, including inpatient and outpatient services, to validate accuracy and appropriateness
Analyze claims against clinical guidelines, medical necessity criteria, and reimbursement policies
Review medical records, physician documentation, and billing data to support claim determinations
Partner with claims operations, coding teams, and utilization management to resolve complex cases
Identify patterns of overpayment, underpayment, or potential fraud/waste/abuse, and escalate as needed
Provide clinical input on appeals, reconsiderations, and dispute resolutions
Ensure adherence to federal/state regulations and industry standards (CMS, NCQA, etc.)
Support audit initiatives and contribute to continuous process improvement efforts
Educate internal stakeholders on documentation and clinical factors impacting claims outcomes

Required Qualifications

Active, unrestricted RN or LVN/LPN license in California
Minimum 2+ years of experience in clinical review, utilization management, or health plan operations
Strong experience with retrospective claims review (this is a core requirement)
Solid understanding of medical necessity criteria and post-service review processes
Familiarity with ICD-10, CPT, and HCPCS coding
Experience working with Medicare Advantage populations strongly preferred
Familiarity with MCG
Familiarity with Division of Financial Responsibility (DOFR) guidelines and their application in utilization management and authorization review.
Proficiency with claims systems (e.g., Facets, QNXT, or similar platforms)
Strong clinical judgment with the ability to apply it in a non-patient-facing, analytical setting
High attention to detail and ability to interpret complex medical documentation
Ability to translate clinical findings into clear claims decisions
Effective collaboration and communication across multidisciplinary teams
Organized, self-directed, and able to manage high-volume workloads

Why This Role

Work remotely with a high-impact team
Focus on analytical, retrospective review work rather than direct patient care
Opportunity to influence payment integrity and healthcare quality outcomes

Job Type: Full-time

Pay: $100,000.00 - $105,000.00 per year

Benefits:

401(k) matching
Dental insurance
Disability insurance
Employee assistance program
Employee discount
Flexible schedule
Flexible spending account
Health insurance
Health savings account
Life insurance
Paid time off
Parental leave
Professional development assistance
Referral program
Retirement plan
Travel reimbursement
Vision insurance

Application Question(s):

Have you performed DRG validation or DRG reviews for claims?
Can you work Monday - Friday, 8am- 5pm PACIFIC hours?

Experience:

CMS Medicare Guidelines: 1 year (Preferred)
Retro Claims Review: 1 year (Required)
Medicare: 1 year (Required)

License/Certification:

Active California RN or LVN Licence (CA is NOT compact) (Required)

Work Location: Remote

Quick Apply

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utilization management nurse jobs in hamilton, tx

Claims Nurse (Utilization Management / Claims Review) Must have CALIFORNIA license

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