Utilization Review Nurse – RN or LVN - Full Remote

Santa Barbara Cottage Hospital; United States; Remote; USD 72,000 - 100,000; Full time

Job summary

Join a leading managed care organization as a Utilization Review Nurse, focusing on ensuring timely and cost-effective care for members. This fully remote position requires an active RN or LVN license, prior authorization experience, and strong communication skills. Ideal for candidates looking to make a difference in underserved communities, the role offers a competitive pay rate and a collaborative team environment.

Qualifications

• Minimum 2 years UM or case management experience in a managed care organization.
• Active, unrestricted RN or LVN license in Texas or a compact state is required.
• Familiarity with InterQual criteria and UM software.

Responsibilities

• Perform concurrent review and prior authorization assessments per company policy.
• Evaluate member eligibility and appropriate level of care.
• Document productivity and maintain quality standards.

Skills

Communication

Organization

Multitasking

Education

Completion of an accredited Registered Nursing or Vocational Nursing program

Tools

InterQual criteria

Microsoft Office

UM software

Job description

Utilization Review Nurse – RN or LVN (Remote, $43/hr, Temp-to-Hire)

Join one of the nation’s leading managed care organizations, committed to transforming health care for underserved communities. Our client is a mission-driven health plan known for delivering accessible, high-quality care to millions of members. With a reputation for innovation and collaboration, they’re looking for compassionate, skilled clinicians to help ensure members receive the right care at the right time — every time.

We are seeking experienced Registered Nurses (RNs) or Licensed Vocational/Practical Nurses (LVNs/LPNs) with prior authorization and/or behavioral health utilization management experience to join a dedicated Utilization Management (UM) team. This is a fully remote, full-time, temporary-to-permanent opportunity starting in July 2025.

Position Details

• Pay Rate: $43.00 per hour

• Schedule: Monday to Friday, 8:00 AM – 5:00 PM (1-hour lunch)

• Work Location: 100% remote

• Licensure: Must hold an active, unrestricted RN or LVN license in Texas or a compact state

Position Summary
The Utilization Review Nurse is responsible for inpatient and outpatient medical necessity review, prior authorizations, and other UM activities. The goal is to ensure members receive appropriate, cost-effective, and timely care while supporting compliance with regulatory standards and promoting positive health outcomes.

Key Responsibilities

• Perform concurrent review and prior authorization assessments per company policy

• Evaluate member eligibility, benefits, and appropriate level of care

• Participate in interdepartmental collaboration (Behavioral Health, Long-Term Care, etc.)

• Document and maintain productivity and quality standards

• Assist in onboarding and mentoring new team members

• Consult regularly with medical directors and escalate as needed

• Represent the organization professionally with internal and external stakeholders

• Adhere to HIPAA, safety, and ethical standards in daily operations

Required Qualifications

• Education: Completion of an accredited Registered Nursing or Vocational Nursing program (comparable experience/education combinations may be considered)

• Experience:

  • Minimum 2 years UM or case management in a managed care organization

  • Experience with prior authorizations and/or behavioral health outpatient services

• Licensure: Active, unrestricted RN or LVN license in Texas or a compact state

• Technical Skills:

  • Familiarity with InterQual criteria and UM software

  • Microsoft Office proficiency (Word, Excel, Outlook)

• Additional Skills:

  • Strong communication, organization, and multitasking

  • Knowledge of NCQA and regulatory standards

  • Ability to work independently and meet deadlines in a fast-paced environment