Top 333 nurse case review Jobs in remote

Utilization Management Physician Reviewer
Toney HealthCare Consulting, LLC —Remote
- From $175 an hour
- Part-time
- Remote
- Medicine
- 3 years
- Senior level
- Health insurance
Quick Apply
Second Level Reviewer I /Clinical Documentation Specialist
AdventHealth Corporate Services —Remote
- $31.81 - $59.16 an hour
- Full-time
- Remote
- Nursing
- RN License
- Mid-level
- Health savings account
- Health insurance
Quick Apply
RN / Medical Reviewer / Remote
InGenesis —Columbia, SC
- Full-time
- Remote
- Nursing
- RN License
- Mid-level
Remote Quality Management RN (Contract)
Upstream Search —Connecticut
- $50 an hour
- Temporary
- Remote
- Microsoft Word
- Background check
- Nursing
- Health insurance
- Dental insurance
Quick Apply
Remote Care Management Nurse
Cambia Health Solutions —Utah
- $38.00 - $41.50 an hour
- Overtime
- Remote
- Background check
- Nursing
- Microsoft Outlook
- Health insurance
- Dental insurance
Quick Apply
Clinical Reviewer (Part-time)
Neil Hoosier & Associates, Inc. —Remote
- $40 - $45 an hour
- Part-time
- Microsoft Excel
- Microsoft Outlook
- RN License
Quick Apply
4d
DRG Appeals Review Nurse
Managed Resources, Inc (MRI) —Remote
- $40 - $45 an hour
- Part-time
- Remote
- Nursing
- RN License
- Writing skills
- Work from home
- Employee discount
Quick Apply
Case Manager Assistant / LPN
MedWatch —Remote
- $23 - $27 an hour
- Full-time
- Remote
- Nursing
- Computer literacy
- Residential
Case Manager Nurse- RN (part-time)
Personify Health —Remote
- $36 - $38 an hour
- Part-time
- Nursing
- RN License
- HIPAA
20h
Utilization Review Nurse (Remote)
tango —Remote
- Weekends as needed
- Remote
- Nursing
- Microsoft Outlook
- RN License
- Health insurance
Quick Apply
1d
Pre-Cert Pharmacy Review Nurse, RN (PBM- Pharmacy experience required)
Quantum Health —Remote
- Remote
- Nursing
- Microsoft Excel
- Microsoft Outlook
Quick Apply
Care Coordinator - Clinical Appeals RN
Premera Blue Cross —Remote
- $80,200 - $143,100 a year
- Online Application
- Nursing
- RN License
- Mid-level
- Free parking
- Wellness program
2d
Clinical Appeals Reviewer (Licensed Healthcare Professional)
Tanaq Support Services LLC —Remote
- Weekends as needed
- Remote
- Nursing
- RN License
- Writing skills
Clinical Documentation Review Nurse
Verse Medical —Remote
- Full-time
- Remote
- Nursing
- RN License
- Mid-level
- Health insurance
- Dental insurance
Nurse Specialist II
Qlarant —Remote
- $56,055 - $83,665 a year
- Remote
- RN License
- Mid-level
- Bachelor's degree
Quick Apply
10d
PRN Medical Legal Analyst
Excelas, LLC —Cleveland, OH
- $35.00 - $45.43 an hour
- Part-time
- Remote
- Nursing
- Writing skills
- Windows
Clinical Documentation Improvement Specialist
Health Information Associates —Remote
- $42 - $48 an hour
- Remote
- RN License
- HIPAA
- Research
Quick Apply
Case Manager / RN
MedWatch —Remote
- $72,000 - $81,000 a year
- Full-time
- Remote
- Nursing
- RN License
- Residential
Utilization Management Nurse - RN
NeueHealth —Remote
- $74,260.46 - $111,390.70 a year
- Full-time
- Remote
- Nursing
- Microsoft Excel
- Microsoft Outlook
- Paid holidays
- Health insurance
Quick Apply
Practice Partner (Registered Nurse)
Florence Provider Network —Remote
- $140,000 - $160,000 a year
- Full-time
- Nursing
- RN License
- Primary Care
- Health savings account
- Health insurance
Quick Apply
4d

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nurse case review jobs near remote

Utilization Management Physician Reviewer

Toney HealthCare Consulting, LLC -
Remote

Quick Apply

Job Details

Part-time | Contract
From $175 an hour

Benefits

Health insurance

Qualifications

Electronic health records (EHR) management
Utilization management
Resource utilization in healthcare
Medical License

Full Job Description

Job Overview

The Physician Reviewer serves as a clinical subject matter expert in the Utilization Management (UM) department. This role is responsible for conducting clinical reviews of medical necessity, appropriateness of care, and service requests based on evidence-based guidelines, medical policy, and regulatory requirements. The Physician Reviewer collaborates with UM nurses, medical directors, and other healthcare professionals to ensure appropriate, timely, and cost-effective care for members.

Key Responsibilities:

Conduct physician-level reviews of prior authorization, concurrent review, and retrospective review cases across multiple lines of business (e.g., commercial, Medicaid, Medicare).
Apply nationally recognized clinical criteria (e.g., MCG, InterQual), internal medical policies, and applicable regulations (CMS, NCQA, URAC) to review determinations.
Render clinical decisions in a timely manner consistent with regulatory timeframes and health plan policies.
Collaborate with medical directors, case managers, and care teams to support optimal care pathways.
Participate in audits, appeals, and grievance processes as needed.
Maintain current knowledge of clinical best practices, industry trends, and regulatory changes.
Participate in peer-to-peer discussions with attending physicians to communicate UM decisions and promote evidence-based care.
Analyze clinical data and documentation to support accurate determinations and appeals.
Contribute to the development and refinement of clinical policies and UM protocols specific to specialized care.
Provide guidance on clinical appropriateness, benefit coverage, and policy interpretation.
Provide education and clinical support to internal teams and external providers regarding best practices and clinical pathways.
Ensure compliance with regulatory, accreditation, and legal requirements in all UM activities.
Ensure adherence to all HIPAA, confidentiality, and privacy standards.
Participate in quality improvement initiatives and clinical case rounds.

Qualifications:

Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree required.
Active and unrestricted medical license.
Minimum of 5 years of clinical practice experience in the respective specialty.
At least 3 years of experience in utilization management within a health plan.
Familiarity with evidence-based guidelines and UM tools (e.g., InterQual, MCG).
Strong communication and documentation skills.
Proficiency with electronic medical records and clinical review platforms.
Experience with Medicare/Medicaid and commercial insurance regulations is preferred.

Preferred Skills:

Experience with Medicare and/or Medicaid managed care plans.
Knowledge of medical necessity appeal processes and peer review protocols.
Knowledge of CMS, NCQA, and/or URAC standards.
Previous peer review or medical director experience.
Comfortable working in a remote, collaborative environment.

Pay: From $175.00 per hour

Experience:

Utilization Management Review: 3 years (Required)
Medicare and/or Medicaid: 2 years (Preferred)

License/Certification:

Board-certified M.D. or D.O. medical license? (Required)

Work Location: Remote

Quick Apply

Refine Your Search

nurse case review jobs in remote

Utilization Management Physician Reviewer

Second Level Reviewer I /Clinical Documentation Specialist

RN / Medical Reviewer / Remote

Remote Quality Management RN (Contract)

Remote Care Management Nurse

Clinical Reviewer (Part-time)

DRG Appeals Review Nurse

Case Manager Assistant / LPN

Case Manager Nurse- RN (part-time)

Utilization Review Nurse (Remote)

Pre-Cert Pharmacy Review Nurse, RN (PBM- Pharmacy experience required)

Care Coordinator - Clinical Appeals RN

Clinical Appeals Reviewer (Licensed Healthcare Professional)

Clinical Documentation Review Nurse

Nurse Specialist II

PRN Medical Legal Analyst

Clinical Documentation Improvement Specialist

Case Manager / RN

Utilization Management Nurse - RN

Practice Partner (Registered Nurse)

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