Remote Utilization Review RN — Contract Opportunity

HealthEdge Software, Inc.; United States; Remote; USD 55,000 - 96,000; Full time

Job summary

HealthEdge Software, Inc. is seeking a highly motivated Utilization Review RN to join our team.

The RN will perform prospective, concurrent and retrospective reviews of inpatient, outpatient, and ancillary services to ensure medical necessity, appropriate length of stay, and level of care, including appeals initiated by providers and members. Responsibilities include authorizing services, coordinating discharge planning, and documenting outcomes while maintaining regulatory standards.

Qualifications

• RN license required (unrestricted).
• Minimum 2 years of clinical experience in discharge planning, case management, or utilization review.

Responsibilities

• Perform prospective, concurrent and retrospective reviews for medical necessity and level of care.
• Authorize services and coordinate care with providers, facilities, and members.
• Document decisions and communicate discharge planning needs to internal/external teams.
• Research and resolve benefit/eligibility issues and coordinate benefits as needed.
• Identify and document quality of care issues and route for resolution.

Skills

Communication skills

Interpersonal skills

Clinical knowledge

Medical necessity assessment

Documentation/writing

Policies and procedures knowledge

Regulatory knowledge

Education

RN license

Case Management Certification (preferred)

Tools

Microsoft Office Suite

Job description

HealthEdge Software, Inc. is seeking a highly motivated Utilization Review RN to join our team.

The RN will perform prospective, concurrent and retrospective reviews of inpatient, outpatient, and ancillary services to ensure medical necessity, appropriate length of stay, and level of care, including appeals initiated by providers and members. Responsibilities include authorizing services, coordinating discharge planning, and documenting outcomes while maintaining regulatory standards.