Remote Utilization Review Nurse – Outpatient

All Care To You; Orange (CA); Remote; USD 90,000 - 120,000; Full time

Job summary

All Care To You is seeking a UM Outpatient Review Nurse to join the Case Management team. You will evaluate authorization requests for medical necessity, apply CMS and health plan criteria, and coordinate with Medical Directors to ensure appropriate care decisions are made.

The role requires clinical expertise, strong documentation, and the ability to maintain high-quality reviews within target turnaround times in a fully remote work environment.

Qualifications

• CA and TX/Multi-State RN or LVN license required.
• CM/UM training or certification preferred.
• 5+ years of clinical experience.
• Experience in HMO/IPA/Managed care preferred.
• Weekend/holiday availability.
• Detail oriented and highly organized.

Responsibilities

• Review authorization requests for medical necessity.
• Process requests within established time frames.
• Document steps in the authorization system.
• Apply CMS and Health Plan criteria.
• Refer complex cases to Medical Director for review.
• Write denial letters meeting CMS/Health Plan requirements.
• Maintain Interrater Reliability rate ≥95%.
• Meet daily production standards for referrals.

Skills

Time management

Multitasking

Communication skills

Confidentiality

Organizational skills

Education

RN/LVN license (CA/TX)

UM/CM training or certification

Tools

Outlook

Microsoft Teams

Zoom

Microsoft Office

Adobe

Job description

All Care To You is seeking a UM Outpatient Review Nurse to join the Case Management team. You will evaluate authorization requests for medical necessity, apply CMS and health plan criteria, and coordinate with Medical Directors to ensure appropriate care decisions are made.

The role requires clinical expertise, strong documentation, and the ability to maintain high-quality reviews within target turnaround times in a fully remote work environment.