Remote Utilization Review Nurse (RN): Clinical Focus

Progressive Technology; Cranberry Township (Butler County); Remote; USD 80,000 - 110,000; Full time

Benefits offered by this job

Health insurance

Flexible working arrangements

Remote work opportunities

Paid time off

Job summary

Progressive Technology is seeking a qualified Utilization Review Nurse to join our clinical operations team. The successful candidate will review medical records, evaluate medical necessity of healthcare services, and ensure decisions align with medical guidelines and regulatory requirements.

The role involves collaboration with healthcare providers, insurance representatives, and case managers to support cost-effective, high-quality patient care.

Qualifications

• Current and unrestricted RN license in the applicable jurisdiction.
• Associate Degree in Nursing (ADN) or Bachelor of Science in Nursing (BSN) from an accredited institution.
• Strong understanding of medical terminology, anatomy, physiology, disease processes, and evidence-based clinical practices.
• Knowledge of utilization management, medical necessity review, and healthcare authorization processes.
• Ability to interpret clinical documentation and apply established medical criteria consistently.
• Excellent analytical, critical-thinking, and clinical decision-making skills.
• Strong written and verbal communication abilities.
• Proficiency in electronic health records, clinical documentation systems, and Microsoft Office applications.
• Ability to manage multiple cases while meeting established productivity and quality standards.

Responsibilities

• Review medical records, clinical documentation, treatment plans, and healthcare service requests to determine medical necessity and appropriateness of care.
• Apply established clinical criteria (InterQual, MCG, and others) to evaluate admissions and procedures.
• Assess whether requested services meet standards, payer policies, and regulatory requirements.
• Conduct prospective, concurrent, and retrospective utilization reviews.
• Ensure compliance with privacy, confidentiality, and information security standards.
• Communicate review findings clearly to providers and internal stakeholders.
• Maintain accurate, confidential documentation of all utilization review activities.
• Collaborate with physicians, case managers, discharge planners, and healthcare professionals to facilitate patient care.

Skills

RN license

Nursing degree (ADN/BSN)

Clinical documentation interpretation

Medical terminology proficiency

Analytical & critical thinking

Communication skills

EHR proficiency

Multitasking in reviews

Education

ADN/BSN nursing degree

Tools

Electronic health records (EHR)

Microsoft Office

Job description

Progressive Technology is seeking a qualified Utilization Review Nurse to join our clinical operations team. The successful candidate will review medical records, evaluate medical necessity of healthcare services, and ensure decisions align with medical guidelines and regulatory requirements.

The role involves collaboration with healthcare providers, insurance representatives, and case managers to support cost-effective, high-quality patient care.