Remote Utilization Review Nurse (RN) – Care Coordination

Evry Healthcare Inc.; United States; Remote; USD 85,000 - 120,000; Full time

Benefits offered by this job

Competitive salary

Health insurance

Company retirement match

Generous PTO

Professional development

Remote-friendly

Job summary

Evry Health seeks an RN Integrated Care Coordinator (UM) to provide comprehensive care coordination and drive quality outcomes for members across the care continuum. This remote role requires rotating weekend hours for utilization review and strong collaboration with providers, facilities, and the clinical team to ensure a positive member experience.

You will perform reviews, coordinate care, and support discharge planning while leveraging data sources and guidelines; a Texas nursing license and

Qualifications

• Must hold current, unrestricted Texas nursing license (or compact license).
• Diploma from an accredited nursing school is required.
• 1–2 years of health plan utilization management experience using standard guidelines.
• Working knowledge of CPT/ICD-10, authorizations, and NCQA/URAC standards.
• 3–5 years of clinical experience in hospital or ambulatory settings.
• Interest/experience in cardiology, pulmonology, women's health, orthopedics, primary care/pediatrics, or oncology.
• Experience outreaching and educating members by phone.
• Bonuses for familiarity with Salesforce/Healthcloud/CareIQ, CCM/ACM and MCG certifications.
• Appeals experience is a bonus.

Responsibilities

• Prepare clinical reviews based on guidelines and present recommendations to physicians for final determination.
• Conduct prior authorization, concurrent, and retrospective reviews focusing on utilization management and discharge planning.
• Monitor quality concerns and escalate issues; identify outliers and long-stay cases.
• Interact with external facilities/providers to gather information for medical necessity reviews.
• Assist with coding, medical records, pre-certification, reimbursement, and denials/appeals.
• Use active listening and motivational interviewing to build trust and engagement.
• Assess discharge planning and care coordination post-discharge.
• Escalate department issues and ensure accountability and closure.
• Collaborate with Medical Director on CM/UM cases.

Skills

Managed care experience

Utilization management

Telephonic outreach

Customer/member engagement

Problem solving

Education

Nursing Diploma

Tools

Salesforce

Healthcloud

CareIQ

Job description

Evry Health seeks an RN Integrated Care Coordinator (UM) to provide comprehensive care coordination and drive quality outcomes for members across the care continuum. This remote role requires rotating weekend hours for utilization review and strong collaboration with providers, facilities, and the clinical team to ensure a positive member experience.

You will perform reviews, coordinate care, and support discharge planning while leveraging data sources and guidelines; a Texas nursing license and