Utilization Review Nurse - 216041

Medix™; United States; Remote; USD 85,000 - 110,000; Full time

Benefits offered by this job

Remote position

Four 10-hour shifts per week

Weekend differential up to 20%

Job summary

Medix™ is seeking a clinically strong, detail-oriented Registered Nurse to join our Utilization Review team in a fully remote role. You will conduct medical necessity reviews, determine appropriate patient status, and collaborate with physicians and payors to support quality patient care and appropriate resource utilization.

The ideal candidate has acute care experience, strong clinical decision-making abilities, and is comfortable working remotely with reliable internet access.

Qualifications

• Strong clinical assessment skills and familiarity with medical necessity criteria.
• Excellent communication and organizational abilities.
• Ability to work independently in a fast-paced, remote environment.

Responsibilities

• Conduct medical necessity reviews for inpatient admissions, observation stays, and continued stays.
• Apply clinical review criteria to determine patient status and level of care.
• Collaborate with physicians, care managers, and payors to obtain documentation.
• Coordinate peer-to-peer reviews and assist with appeals and denial management.
• Monitor denial trends, quality indicators, and revenue cycle workflows.

Skills

Clinical assessment

Communication

Organization

Problem solving

Independent work

Education

Bachelor's degree in Nursing

Job description

Are you an RN looking to transition into or grow your career in Utilization Review? We're seeking a clinically strong, detail-oriented Registered Nurse to join our Utilization Review team!

This is a great opportunity for nurses with acute care experience who enjoy clinical decision-making, medical necessity reviews, and collaborating with providers to support quality patient care and appropriate resource utilization.

What You'll Do

• Conduct medical necessity reviews for inpatient admissions, observation stays, and continued stays.
• Apply clinical review criteria to determine appropriate patient status and level of care.
• Collaborate with physicians, care managers, and insurance payors to obtain clinical documentation and support appropriate care decisions.
• Coordinate peer-to-peer (P2P) reviews and assist with appeals and denial management.
• Identify potential overutilization, barriers to patient progress, and opportunities to improve patient outcomes.
• Monitor denial trends, readmissions, quality indicators, and revenue cycle workflows.
• Maintain accurate documentation while supporting regulatory and payer requirements.
• Four 10-hour shifts per week with an additional day off.
• Rotating schedule with every other weekend required.
• Available shifts:
• 10:00 AM-8:00 PM
• 12:00 PM-10:00 PM
• 10% evening shift differential for eligible hours worked on the 12:00 PM-10:00 PM shift.
• Differentials may combine for up to 20% additional pay on eligible weekend hours worked during the later shift.

The team provides coverage seven days a week between 8:00 AM and 10:00 PM, so flexibility with shift assignments is essential.

Qualifications

• Current, unrestricted Registered Nurse (RN) license.
• Must have an active compact RN license or be willing to obtain one.
• Bachelor's degree in Nursing or a related field, or equivalent experience.
• Three years of acute care nursing experience preferred.
• Familiarity with medical necessity criteria and quality improvement processes preferred.
• Strong clinical assessment, communication, organization, and problem-solving skills.
• Ability to work independently in a fast-paced, remote environment.
• Reliable high-speed internet access.
• Willingness to travel onsite to client, temporary, or corporate locations as business needs require.

Why Consider This Opportunity?

• Fully remote position with a four-day workweek.
• Opportunity to apply your clinical expertise beyond the bedside.
• Additional earning potential through shift and weekend differentials.
• Collaborative environment working with physicians, care managers, and healthcare partners.
• Opportunity to contribute to quality patient care, appropriate resource utilization, and improved healthcare outcomes.