Utilization Management Registered Nurse

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

Benefits offered by this job

100% Remote work

Competitive compensation

Opportunity for process optimization

Job summary

Appworkshub is seeking a dedicated and detail-oriented Utilization Management Registered Nurse (UM RN) to join our remote healthcare team. In this role, you will conduct inpatient and outpatient utilization reviews, support transitions of care, and ensure compliance with Medicare Advantage regulations. The ideal candidate will have strong clinical judgment, a valid RN license, and 3+ years of experience in utilization management. We offer competitive compensation, a collaborative environment, and work-life balance.

Qualifications

• 3+ years of Utilization Management or related clinical review experience.
• Proven experience with Skilled Nursing Facility (SNF) utilization reviews.
• Strong familiarity with MCG criteria and Medicare Advantage rules.
• Prior experience in prior authorization (PA) and Transitions of Care (TOC) workflows.

Responsibilities

• Conduct clinical reviews of inpatient, outpatient, and SNF services.
• Evaluate and process prior authorization (PA) requests.
• Collaborate with inpatient providers and case managers.
• Ensure compliance with Medicare Advantage and federal regulations.
• Maintain accurate documentation in electronic platforms.

Skills

Clinical judgment

Inpatient/SNF experience

Familiarity with MCG guidelines

Understanding Medicare Advantage regulations

Effective communication skills

Attention to detail

Education

Active, unrestricted RN license

Tools

AcuityNxt

Job description

We’re seeking a dedicated and detail-oriented Utilization Management Registered Nurse (UM RN) to join our growing healthcare team. In this role, you’ll perform both inpatient and outpatient utilization reviews while supporting transitions of care and ensuring patients receive appropriate, timely, and high-quality services.

The ideal candidate will bring strong clinical judgment, inpatient/SNF experience, and familiarity with MCG guidelines and Medicare Advantage regulations (LCD/NCD policies). This is a fully remote opportunity requiring discipline, accuracy, and effective collaboration across virtual teams.

Key Responsibilities:

Conduct clinical reviews of inpatient, outpatient, and SNF services to assess medical necessity, appropriateness, and efficiency using evidence-based criteria (e.g., MCG).

Evaluate and process prior authorization (PA) requests in a timely, compliant manner.

Collaborate with inpatient providers and case managers to support Transitions of Care (TOC) and discharge planning.

Communicate clearly with interdisciplinary teams to ensure coordinated and effective care delivery.

Maintain accurate, comprehensive documentation in systems such as AcuityNxt and other electronic platforms.

Ensure compliance with Medicare Advantage, state, and federal healthcare regulations.

Contribute to process improvement initiatives to enhance overall UM effectiveness and efficiency.

What You’ll Bring:

Active, unrestricted RN license (state-specific or compact).

3+ years of Utilization Management or related clinical review experience.

Proven experience with Skilled Nursing Facility (SNF) utilization reviews.

Strong familiarity with MCG criteria, LCD/NCD policies, and Medicare Advantage rules.

Prior experience in prior authorization (PA) and Transitions of Care (TOC) workflows.

Excellent clinical communication skills and confidence in engaging with inpatient providers.

Strong attention to detail, documentation accuracy, and compliance focus.

Tech-savvy with the ability to quickly adapt to healthcare systems and remote work tools.

Why Join Us:

100% Remote role – enjoy work-life balance while supporting patients across the continuum of care.

Collaborative, mission-driven healthcare environment.

Opportunity to expand into Transitions of Care (TOC) initiatives and process optimization.

Competitive compensation and benefits package.