Senior Utilization Nurse – Real-Time Reviews (Remote)

Folioworks; California (MO); Hybrid; USD 90,000 - 115,000; Full time

Benefits offered by this job

Remote work possible

Collaborative environment

Coordinated care model

Job summary

Folioworks is seeking a skilled Registered Nurse to perform concurrent utilization reviews for inpatient and post-acute services, ensuring medical necessity and appropriate level of care. The role involves authorizations, documentation review, discharge planning, and collaboration with care teams.

The ideal candidate has California nursing licensure, 4+ years of nursing experience, and familiarity with utilization review in managed care.

Qualifications

• Active, unrestricted California RN or LVN/LPN license.
• Minimum 4 years of clinical nursing experience.
• At least 1 year of utilization review or case management experience.
• Experience with medical necessity reviews in a managed care setting.
• Strong knowledge of clinical guidelines and utilization management criteria.
• Proficiency with EHR systems, utilization management software, and Microsoft Office.

Responsibilities

• Conduct real-time reviews of inpatient and skilled nursing services using medical necessity criteria and clinical guidelines.
• Evaluate clinical documentation to support admission decisions, continued stays, level-of-care determinations, and treatment plans.
• Process authorization requests for inpatient, LTAC, inpatient rehab, and skilled nursing admissions.
• Communicate with providers to request additional information, clarify treatment plans, and resolve utilization review questions.
• Coordinate with case managers, social workers, and care teams to support discharge planning and care transitions.
• Escalate complex, borderline, or denied cases to the Medical Director for review.
• Maintain accurate documentation of reviews, authorizations, denials, escalations, and clinical decisions.
• Participate in interdisciplinary meetings and support quality improvement efforts related to utilization trends.

Skills

Nursing experience

Utilization review

EHR proficiency

Discharge planning

Provider communication

Microsoft Office

Education

RN license

BSN

Tools

EHR systems

Utilization management software

Microsoft Office

Job description

Folioworks is seeking a skilled Registered Nurse to perform concurrent utilization reviews for inpatient and post-acute services, ensuring medical necessity and appropriate level of care. The role involves authorizations, documentation review, discharge planning, and collaboration with care teams.

The ideal candidate has California nursing licensure, 4+ years of nursing experience, and familiarity with utilization review in managed care.