Remote Utilization Review RN (Contract)

Wellframe; United States; Remote; USD 70,000 - 90,000; Full time

Job summary

HealthEdge is seeking a highly motivated Utilization Review RN to join our team. The role involves prospective, concurrent and retrospective reviews to ensure medical necessity and appropriate level of care across inpatient and outpatient settings.

The position supports remote work in the US, requires an unrestricted RN license and may include responsibilities around discharge planning, documentation, and coordination with providers and plans.

Qualifications

• RN with current unrestricted license.
• Experience in utilization review or case management preferred.
• Knowledge of NCQA and accreditation standards or familiarity with regulatory guidelines.

Responsibilities

• Perform prospective, concurrent, and retrospective review of services for medical necessity and level of care.
• Coordinate with providers and facilities to determine alternative plans and discharge planning needs.
• Research and document benefits, eligibility, and coordination of benefits across cases.

Skills

Clinical reasoning

Communication skills

Office software

Care coordination

Medical policy knowledge

Tools

Microsoft Office

Job description

HealthEdge is seeking a highly motivated Utilization Review RN to join our team. The role involves prospective, concurrent and retrospective reviews to ensure medical necessity and appropriate level of care across inpatient and outpatient settings.

The position supports remote work in the US, requires an unrestricted RN license and may include responsibilities around discharge planning, documentation, and coordination with providers and plans.