Remote Utilization Review Nurse (CA) – Managed Care

Spectraforce; California; Remote; USD 55,000 - 69,000; Full time

Job summary

Spectraforce is seeking an Utilization Review Registered Nurse (Post-service Medical Review 3) for remote work in California. The role focuses on retrospective utilization reviews, medical necessity assessments, and line-by-line audit of hospital bills to ensure contract compliance and proper billing practices.

Strong RN credentials in California and CMS guideline proficiency are required. Ideal candidates will have 5+ years in managed care, experience with inpatient reviews, and solid EMR and

Qualifications

• Requires independent motivation, strong work ethic and strong computer navigations skills.
• Requires at least 5 years of prior relevant experience.
• Previous managed care experience including inpatient claims or concurrent review preferred.
• Requires a current California RN License.

Responsibilities

• Perform retrospective utilization reviews and first level determinations.
• Conduct clinical review of claims for medical necessity, coding accuracy, policy and contract compliance.
• Prepare and present cases to Medical Director for oversight and communicate determinations to providers and members.
• Develop and review member documentation reflecting determinations and identify care delays.
• Clearly communicates, collaborates, and works effectively and efficiently.
• Review itemizations for coding logic using CMS guidelines.
• Triages and prioritizes cases to meet turnaround times.
• Identifies potential quality of care issues and delays as clinically appropriate.
• Apply clinical judgment and knowledge of benefit plans to complete review decisions.

Job description

Spectraforce is seeking an Utilization Review Registered Nurse (Post-service Medical Review 3) for remote work in California. The role focuses on retrospective utilization reviews, medical necessity assessments, and line-by-line audit of hospital bills to ensure contract compliance and proper billing practices.

Strong RN credentials in California and CMS guideline proficiency are required. Ideal candidates will have 5+ years in managed care, experience with inpatient reviews, and solid EMR and