Remote RN Utilization Review Specialist

HealthHelp; Houston (TX); On-site; USD 65,000 - 75,000; Full time

Job summary

HealthHelp is seeking a remote Utilization Review clinician (RN/LPN/LVN) to support medical necessity determinations across client programs. You will review cases, coordinate with providers, and ensure timely decisions in line with policy and regulatory requirements.

Ideal candidates bring 2+ years in utilization review or case management, strong clinical knowledge, and proficiency with Microsoft Office and healthcare software.

Qualifications

• RN or LPN/LVN license in the U.S. is required.
• Minimum 2 years in utilization review, case management, or clinical quality improvement.
• Proficient in Microsoft Office and adaptable to healthcare software.
• Experience with state and federal regulatory standards is preferred.
• Knowledge of National Coverage Determination (NCD) and Local Coverage Determination (LCD).

Responsibilities

• Perform utilization review to determine medical necessity per client policies.
• Facilitate resolution of escalated cases requiring special handling.
• Collaborate with client personnel to resolve customer concerns.
• Maintain documentation per HealthHelp policy and regulatory requirements.
• Ensure HIPAA, state, and federal compliance in clinical reviews.

Skills

Communication skills

Time management

Critical thinking

Independence

Team collaboration

Education

RN/LPN/LVN license (US)

Tools

Microsoft Office

EMR/Healthcare software

Job description

HealthHelp is seeking a remote Utilization Review clinician (RN/LPN/LVN) to support medical necessity determinations across client programs. You will review cases, coordinate with providers, and ensure timely decisions in line with policy and regulatory requirements.

Ideal candidates bring 2+ years in utilization review or case management, strong clinical knowledge, and proficiency with Microsoft Office and healthcare software.