Remote Utilization Review Nurse - Outpatient

All Care To You; United States; Remote; USD 85,000 - 110,000; Full time

Benefits offered by this job

Full benefits

Unlimited PTO

Birthday off

401k plan

Paid holidays

Job summary

All Care To You is seeking a UM Outpatient Review Nurse to join our Case Management team. This remote role emphasizes clinical review, medical necessity determinations, and collaboration with health plans, providers, and members to support high-quality patient outcomes.

You will apply CMS, NCQA, and clinical guidelines to determine coverage, maintain high interrater reliability, and meet turnaround times for urgent and routine reviews.

Qualifications

• Valid CA and Texas/Multi-State RN or LVN license.
• CM and/or UM training and/or certification; knowledge of CM standards, UM standards, clinical standards of care, NCQA, CMS, Miliman, InterQual.
• Five years+ clinical experience.
• 2+ years experience in HMO/IPA/Managed care setting preferred.

Responsibilities

• Review authorization requests for medical necessity and determine need for Medical Director review.
• Process requests within established timeframes.
• Document steps in authorization system and notes.
• Apply CMS/Health Plan criteria and clinical guidelines to determine coverage.

Skills

RN License

CM/UM training

Clinical experience

HMO/Managed care

Communication skills

Tools

Outlook

Microsoft Teams

Zoom

Microsoft Office

Job description

All Care To You is seeking a UM Outpatient Review Nurse to join our Case Management team. This remote role emphasizes clinical review, medical necessity determinations, and collaboration with health plans, providers, and members to support high-quality patient outcomes.

You will apply CMS, NCQA, and clinical guidelines to determine coverage, maintain high interrater reliability, and meet turnaround times for urgent and routine reviews.