Utilization Review Nurse, RN – Part-Time

Job Description:

  • Perform utilization management medical-necessity reviews and level-of-care determinations for requested services
  • Apply benefit language, plan documents, medical policies, evidence-based criteria such as MCG and NCCN, and state/federal requirements
  • Route requests that do not meet criteria to the Medical Director for secondary clinical review
  • Analyze clinical documentation for completeness and identify risk, acuity indicators, inconsistencies, or missing information
  • Initiate timely outreach and escalation according to utilization-management workflow
  • Prioritize workload based on urgency, regulatory/accreditation time frames, and member impact
  • Assist with in-network and benefit-compliant redirection by confirming eligibility, benefits, authorization requirements, and network status
  • Support appeals by preparing clinical summaries and documentation and coordinating peer-to-peer/Medical Director discussions
  • Document reviews, rationale, criteria or policy citations, communications, and outcomes in designated utilization-management systems
  • Meet productivity, quality, accuracy, and turnaround-time standards
  • Participate in calibration and quality activities and incorporate feedback
  • Maintain HIPAA compliance and confidentiality
  • Complete required training and annual competencies
  • Cross-train and provide cross-coverage to support team operations and service-level commitments

Requirements:

  • Current, unrestricted RN license in the United States or U.S. territory; compact license acceptable where applicable
  • Graduate of an accredited nursing program; ADN or diploma required
  • BSN preferred
  • Minimum 1–2 years of recent clinical experience, such as acute care, med-surg, ICU/ED, or another relevant setting
  • Prior utilization review/utilization management experience preferred
  • Ability to interpret medical records and apply evidence-based criteria and plan medical policies
  • Basic computer literacy upon hire
  • Ability to work on multiple screens and proficient typing skills
  • Proficiency with Microsoft Word, Microsoft Excel, Outlook, and similar software applications
  • Excellent verbal and written communication skills
  • Ability to communicate complex or technical information clearly and understand complex information from others
  • Ability to work independently and use written resources to solve problems
  • Knowledge of medical claims and ICD-10, CPT, and HCPCS coding
  • Ability to perform essential job functions safely and successfully, with or without reasonable accommodation
  • Ability to maintain regular, punctual attendance
  • Ability to sit for 6–8 hours
  • Constant computer keyboard and mouse use with repetitive use of both hands
  • Occasional to frequent twisting of the neck and occasional bending of the neck and waist
  • Weekends required
  • Up to 28 hours per week

Benefits:

  • Competitive base salary and benefits effective day one
  • Comprehensive medical and dental through our own health solutions
  • Paid Time Off
  • Mental health support
  • Retirement planning
  • Financial protection
  • Professional development with clear career progression and learning budgets
  • Mission-driven culture where diverse perspectives drive real impact
  • Wellness programs
  • Other employee perks
  • Full benefits package starting day one
Back to blog

Other Jobs To Apply

Hobby Lobby New Job Openings $30/Hour

Eddie Bauer Work From Home Jobs (Customer Support) $75000/Year

Manager, GTM - UCANZ (Contract)

Remote Account Support Specialist – Hulu Subscriber Retention & Escalation

[Remote] Senior Consultant, Account Services Management - Plano, Texas

Customer Service Rep (100% Work From Home)

Inside Sales Representative (Remote - Western Region)

Data Entry

Sr Patient Accounting Representative, Full Time, First Shift, Remote

Customer Service Representative - Lab (Remote)

Remote Jobs Wells Fargo, Wells Fargo Jobs Remote – Job ID- 403 Job ID- 2576

Aetna Cvs Work From Home

SAP MDG Enterprise Asset Management Functional Consultant Remote / Telecommute Jobs

ServiceNow Functional Lead 102420 Remote / Telecommute Jobs

Virtual Performance Integration Manager - GM Defense

REMOTE: Insurance Sales Representative

Virtual Health Technician II

English Screener

Clinical Application Specialist - Digital Implementation Services

Incident Response Consultant (Remote)

Staff Embedded Software Engineer, Virtualization

Field Medical Advisor, Oncology

Manager, Training Delivery (Remote)

Director, Creator & Affiliate Marketing

Senior AI Solutions Architect (RapidScale) (Remote)

Security Consulting Engineer(Remote)

Supervisor Employee Services Contact Center - REMOTE

Bilingual Spanish Part Time Retail Sales Consultant

Lead Strategist Project Based

Account Executive, SMB Team Sales - Miami, FL

[Remote] Senior Data Product Manager, CMC Digital

US Director of Medical Affairs (US DMA) – Infectious Diseases and Vaccines (Respiratory), Remote

Senior Product Service Specialist - Water Heaters (Remote - US Only - Must Reside in the Central ...

Lead Graphic Designer, Accessories (Remote)

Boeing Virtual Information Session - Fall 2026 [Remote]

Remote Operator (Spring, TX)

Marcus by Goldman Sachs, Complaints Specialist, Richardson, TX/Draper, UT

Staff Software Engineer at Block, Inc.: 100% Remote (New York, NY)

Community College Veterans Information Session with Bank of America

Principal Technical Writer - Customer Onboarding

CONFIGURATION SPECIALIST(MONDAY.COM)

Azure and GitHub Consultant

Finance Manager, Marketing

Amex Work From Home Jobs

Work From Home Jobs At Walmart $24/Hour

The Walt Disney Company is hiring: Remote Spanish Sports Video Content Creator i

Junior/Mid AI Video Artist (Full Remote - Worldwide)

Data Entry Clerk Work From Home - Part-Time Focus Group Participants (Up To $750/Week)

Online Typing Jobs (Remote Position)

SE Region for CDL A Drivers. Top 50% Avg. $81,172