Remote Utilization Management RN - SNF & TOC Expert

Appworkshub; United States; Remote; USD 70,000 - 90,000; Full time

Benefits offered by this job

100% Remote work

Competitive compensation

Opportunity for process optimization

Job summary

Appworkshub is seeking a dedicated and detail-oriented Utilization Management Registered Nurse (UM RN) to join our remote healthcare team. In this role, you will conduct inpatient and outpatient utilization reviews, support transitions of care, and ensure compliance with Medicare Advantage regulations. The ideal candidate will have strong clinical judgment, a valid RN license, and 3+ years of experience in utilization management. We offer competitive compensation, a collaborative environment, and work-life balance.

Qualifications

• 3+ years of Utilization Management or related clinical review experience.
• Proven experience with Skilled Nursing Facility (SNF) utilization reviews.
• Strong familiarity with MCG criteria and Medicare Advantage rules.
• Prior experience in prior authorization (PA) and Transitions of Care (TOC) workflows.

Responsibilities

• Conduct clinical reviews of inpatient, outpatient, and SNF services.
• Evaluate and process prior authorization (PA) requests.
• Collaborate with inpatient providers and case managers.
• Ensure compliance with Medicare Advantage and federal regulations.
• Maintain accurate documentation in electronic platforms.

Skills

Clinical judgment

Inpatient/SNF experience

Familiarity with MCG guidelines

Understanding Medicare Advantage regulations

Effective communication skills

Attention to detail

Education

Active, unrestricted RN license

Tools

AcuityNxt

Job description

Appworkshub is seeking a dedicated and detail-oriented Utilization Management Registered Nurse (UM RN) to join our remote healthcare team. In this role, you will conduct inpatient and outpatient utilization reviews, support transitions of care, and ensure compliance with Medicare Advantage regulations. The ideal candidate will have strong clinical judgment, a valid RN license, and 3+ years of experience in utilization management. We offer competitive compensation, a collaborative environment, and work-life balance.