Registered Nurse – Remote Utilization Review

Registered Nurse – Remote Utilization Review Location: Remote (must work Pacific Standard Time) Duration: 13 weeks Schedule: Monday–Friday, 8:00 AM–4:30 PM PST (5x8-hour day shifts) Weekend Requirement: Every other weekend rotation Overview: We are seeking a dedicated and detail-oriented Utilization Review Nurse to join our healthcare team. This role is essential in ensuring that patients receive appropriate care while adhering to established guidelines and standards. The ideal candidate will possess a strong clinical background, excellent analytical skills, and a thorough understanding of medical documentation and coding.

Perform concurrent and retrospective utilization reviews for hospital admissions and continued stays Apply InterQual criteria to determine medical necessity and appropriate level of care Collaborate with physicians, case managers, and insurance representatives for care coordination Handle appeals, denials, prior authorizations, and benefits eligibility reviews Ensure compliance with CMS, CA Medi-Cal, and Joint Commission regulations Maintain accurate and timely documentation within Epic Participate in weekend rotation (every third weekend) and maintain flexibility across assigned facilities Follow all California labor laws regarding breaks, overtime, and work schedules