Remote Senior Utilization Review Specialist

Sage-Clinical-Rcm,-LLC; United States; On-site; USD 55,000 - 83,000; Part time

Job summary

Sage Clinical RCM is seeking a Part-Time Senior Utilization Review Specialist, an experienced registered nurse responsible for concurrent and retrospective review of hospital services to support appropriate utilization and medical necessity compliance.

This senior individual-contributor role partners with physicians, care management, coding, patient access, and revenue cycle teams to reduce denials and support timely reimbursement.

Qualifications

• Five+ years of acute-care hospital experience, including at least three years in utilization review or related function.
• Experience applying medical-necessity and level-of-care criteria.
• Knowledge of inpatient vs observation status and payer authorization requirements.
• Strong clinical judgment, prioritization, documentation, and communication.
• Ability to independently manage a high-volume, deadline-driven caseload.

Responsibilities

• Perform concurrent and retrospective utilization reviews for assigned inpatient, observation, and outpatient cases using approved criteria, payer policies, and clinical judgment.
• Apply InterQual, MCG, or client-approved criteria to support medical necessity, level of care, continued stay, and patient-status determinations.
• Obtain, submit, and track payer notifications and authorizations; communicate clinically relevant information to payer medical-management teams within required time frames.
• Identify potential medical-necessity, authorization, status, and documentation risks early and elevate appropriately to prevent avoidable denials.
• Collaborate with physicians, case management, CDI, coding, patient access, and revenue cycle partners to clarify documentation and support appropriate care progression.
• Coordinate clinical information and deadlines for peer-to-peer review or denial escalation when needed; maintain complete, accurate documentation in the designated systems.
• Serves as a member of the Utilization Review Committee-prepares reports to include utilization trends, denial patterns, extended stays, and workflow barriers; communicate actionable findings to leadership.
• Performs escalations to UR Committee members to ensure compliance with regulations for patient status changes by providers are occurring per policy. Documents escalations and presents outcomes to UR committee.
• Serve as a senior clinical resource, providing guidance and support on complex review questions while adhering to established policies and escalation pathways.
• Participate in quality audits, education, process improvement, and other initiatives that strengthen utilization management performance.

Skills

Acute-care experience

Utilization review

Case management

Medical necessity

Payer authorization

Communication

Documentation

HIPAA compliance

Education

BSN

Tools

InterQual

MCG

Cerner

Job description

Sage Clinical RCM is seeking a Part-Time Senior Utilization Review Specialist, an experienced registered nurse responsible for concurrent and retrospective review of hospital services to support appropriate utilization and medical necessity compliance.

This senior individual-contributor role partners with physicians, care management, coding, patient access, and revenue cycle teams to reduce denials and support timely reimbursement.