Remote Utilization Review RN (Contract)

HealthEdge; United States; Remote; USD 85,000 - 110,000; Part time

Job summary

HealthEdge seeks a motivated Utilization Review RN to perform prospective, concurrent, and retrospective reviews of inpatient, outpatient, ambulatory, and ancillary services to ensure medical necessity and appropriate care levels.

The role includes discharge planning, care coordination, and appeals support, with remote work across the US. RN licensure is required; CM certification is preferred and encouraged.

Qualifications

• Registered Nurse with current unrestricted RN license.
• Certification in Case Management preferred; encouraged.
• Minimum of 2 years’ clinical experience (acute care, discharge planning, case management, or utilization review).
• 1 year health insurance plan experience or managed care preferred.

Responsibilities

• Review and authorize requests for elective, direct, ancillary, urgent, and emergency services.
• Analyze retrospective reviews and appeals per regulatory/accreditation standards.
• Coordinate discharge planning with internal and external teams.
• Identify patterns of care and coordinate delivery of services.
• Resolve benefits, eligibility, and coordination of care issues.
• Follow up on out-of-network services and arrange in-network transfers.
• Develop and deliver provider education on policies and benefits.

Skills

Communication skills

Clinical knowledge

Microsoft Office

Education

RN license

Tools

Microsoft Office

Job description

HealthEdge seeks a motivated Utilization Review RN to perform prospective, concurrent, and retrospective reviews of inpatient, outpatient, ambulatory, and ancillary services to ensure medical necessity and appropriate care levels.

The role includes discharge planning, care coordination, and appeals support, with remote work across the US. RN licensure is required; CM certification is preferred and encouraged.