Remote RN: Clinical Review for Utilization Management

Piedmont; Augusta (MI); On-site; USD 47,000 - 55,000; Full time

Benefits offered by this job

Medical, dental & vision

401(k) Retirement Plan

Pre‑tax and Roth post‑tax

Life Insurance

Disability insurance

HSA

Transit benefits

Employee Assistance Program

PTO / Vacation / Sick Leave

Job summary

Actalent is seeking a Clinical Review Nurse for a fully remote role to conduct medical necessity reviews and evaluate clinical documentation. You will ensure compliance with guidelines and collaborate with interdisciplinary teams to support quality and cost‑effective care.

The role requires an RN license, 2+ years in Utilization Management, and familiarity with InterQual/MCG guidelines. Location is remote within the United States; eligible candidates will be paid hourly and eligible for standard

Qualifications

• Active, unrestricted compact RN license in good standing.
• Associate's or Bachelor's degree in Nursing.
• 2+ years of experience in Utilization Management.
• Experience with Medicare, Medicaid, Commercial Health Plans, or Managed Care programs.
• Knowledge of InterQual, MCG, or other clinical decision‑support guidelines.

Responsibilities

• Perform clinical reviews to determine medical necessity, appropriateness of care, and level of service.
• Review medical records, provider documentation, treatment plans, and related clinical information.
• Apply evidence‑based guidelines, regulatory standards, and company policies during the review process.
• Collaborate with physicians, healthcare providers, case managers, and other interdisciplinary teams.
• Document review findings thoroughly and accurately within designated systems.
• Identify opportunities to improve quality of care, member outcomes, and cost‑effective healthcare delivery.
• Ensure compliance with federal, state, and accreditation requirements.
• Participate in audits, quality improvement initiatives, and process enhancements.
• Maintain productivity, quality, and turnaround‑time standards.
• Stay current on clinical best practices, healthcare regulations, and review criteria.

Skills

RN license

Utilization Management

Medicare/Medicaid experience

Clinical guidelines InterQual/MCG

Education

Associate's or Bachelor's degree in Nursing

Job description

Actalent is seeking a Clinical Review Nurse for a fully remote role to conduct medical necessity reviews and evaluate clinical documentation. You will ensure compliance with guidelines and collaborate with interdisciplinary teams to support quality and cost‑effective care.

The role requires an RN license, 2+ years in Utilization Management, and familiarity with InterQual/MCG guidelines. Location is remote within the United States; eligible candidates will be paid hourly and eligible for standard