Remote Utilization Review RN – CA Licensed, Mon-Fri

Actalent; United States; A distancia; USD 69.000 - 76.000; Jornada completa

Descripción de la vacante

Actalent is seeking an experienced Utilization Review RN for a remote MondayFriday opportunity with a CA-based license requirement. The role reviews clinical information, applies criteria, and makes first-level recommendations to ensure regulatory turnaround times are met.

Responsibilities include completing prospective reviews, applying guidelines, and escalating denials as needed. This contract position is remote with a Sacramento, CA origin and a pay range of $50–$55 per hour.

Formación

• Active California RN license.
• 5+ years of nursing experience, inpatient.
• Utilization Review/Utilization Management experience required.
• Experience with Post-Service Review, Prior Authorization, and/or Concurrent Review.
• Knowledge of ICD-10 and clinical documentation.
• Excellent Windows/computer skills; ability to navigate multiple systems.
• Strong organization and case-prioritization skills.

Responsabilidades

• Complete prospective clinical reviews
• Apply evidence-based guidelines and nationally recognized clinical criteria
• Review diagnoses for appropriate ICD-10 alignment
• Triage urgent and standard cases according to required turnaround times
• Develop approval or denial recommendations
• Escalate denial recommendations to Medical Directors when required
• Communicate determinations to providers and/or members
• Document reviews in accordance with regulatory and accreditation requirements
• Identify potential quality-of-care concerns and treatment/service delays
• Identify potential Third-Party Liability and Coordination of Benefits cases

Conocimientos

Utilization Review/Utilization Mgmt

Nursing experience

ICD-10 knowledge

Medical necessity/clinical review

Windows/computer skills

Organization & prioritization

Inpatient clinical experience

Descripción del empleo

Actalent is seeking an experienced Utilization Review RN for a remote MondayFriday opportunity with a CA-based license requirement. The role reviews clinical information, applies criteria, and makes first-level recommendations to ensure regulatory turnaround times are met.

Responsibilities include completing prospective reviews, applying guidelines, and escalating denials as needed. This contract position is remote with a Sacramento, CA origin and a pay range of $50–$55 per hour.