Remote Utilization Review Nurse Auditor (RN + Coding)

ExamWorks, Inc.; United States; Remote; USD 70,000 - 90,000; Full time

Job summary

ExamWorks is seeking a Utilization Review Nurse Auditor for a 100% remote role with standard EST hours (Mon–Fri, 8:00am–5:00pm EST). The ideal candidate is a licensed nurse with coding certification and at least 3–5 years of patient care, experienced in utilization management and compliance with URAC and federal/state guidelines.

Responsibilities include conducting quality reviews, documenting findings, and ensuring timely determination letters while coordinating with providers and client

Qualifications

• Active unencumbered nursing license (RN/LPN/LVN) required.
• Graduation from an accredited nursing program; bachelor's degree preferred.
• Minimum of three to five years of direct professional patient care.
• Current coding certification in OASIS, RAC-CT, CCS, CPC, RHIT or RHIA; CPMA certification preferred.
• Experience in utilization management and knowledge of medical terminology.
• Proficient typist (40 WPM) and basic computer skills.

Responsibilities

• Perform quality utilization review through evidence-based guidelines for peer review reports and addendums.
• Work with providers to identify level, intensity and duration of care.
• Document findings and evaluate medical necessity for frequency, intensity and length of required care.
• Ensure reviews meet or exceed industry standards and client turnaround times.
• Maintain knowledge of URAC and federal/state regulatory requirements.
• Maintain accurate records of Utilization Reviews within the database.
• Direct Customer Service Representatives to ensure timely delivery of determination letters.
• Assist in resolution of client complaints and QA issues as needed.
• Ensure adherence to ERISA, URAC and state guidelines at all times.
• Provide insight to management on compliance concerns regarding policies and client specifications.
• Participate in meetings, training and continuing education.

Skills

Nursing license

coding certification

Education

High school diploma or equivalent

Accredited nursing program graduate; bachelor's degree preferred

Job description

ExamWorks is seeking a Utilization Review Nurse Auditor for a 100% remote role with standard EST hours (Mon–Fri, 8:00am–5:00pm EST). The ideal candidate is a licensed nurse with coding certification and at least 3–5 years of patient care, experienced in utilization management and compliance with URAC and federal/state guidelines.

Responsibilities include conducting quality reviews, documenting findings, and ensuring timely determination letters while coordinating with providers and client