Virtual Utilization Review Nurse - 259398

Medix™; United States; Remote; USD 90,000 - 120,000; Full time

Job summary

Medix is seeking a registered nurse for Utilization Review (UR) on a remote, full-time basis. The role involves medical necessity and level-of-care reviews across all ages, with a 4x10 schedule and every-other-weekend requirement. Evening hours from 12:00 PM to 10:00 PM receive a 10% differential.

The position requires ICU/ED/OR clinical experience, strong quality-improvement skills, and flexibility to travel occasionally to corporate/client sites.

Qualifications

• Active, unrestricted RN license (Compact RN preferred).
• Direct clinical experience in ICU, ED, or OR.
• Knowledge of quality improvement processes.

Responsibilities

• Perform medical necessity and level-of-care reviews across age groups.
• Detect and address over- and under-utilization and patient care barriers.
• Submit clinical documentation to carriers and FCC within 1 business day of admission.
• Coordinate physician advisor referrals and reviews.
• Collaborate with revenue cycle teams to resolve billing issues and denial trends.
• Train staff on UR processes, regulatory updates, and payer rules.
• Adhere to FCC communication guidelines across channels.
• Adopt new technologies to streamline workflows.

Skills

Clinical judgment

Payer negotiation

Time management

AI/tech tools

Education

RN license

Tools

Remote setup

Job description

Schedule:

Full-Time | 4x10 Schedule (Four 10-hour shifts/week) | Every other weekend required

Shift Hours:

10:00 AM - 8:00 PM OR 12:00 PM - 10:00 PM

Location:

Remote (Requires high-speed internet; subject to occasional travel to corporate/client sites)

Pay & Differential Premiums

• 10% Evening Differential: For hours worked between 12:00 PM and 10:00 PM.

Responsibilities

Medical Necessity & Level of Care

• Perform medical necessity and level-of-care reviews (admission, continued stay, observation) across all age groups using clinical criteria.
• Detect and address over- and under-utilization and patient care barriers.
• Submit clinical documentation to commercial carriers and the Financial Clearance Center (FCC) within 1 business day of admission.
• Coordinate physician advisor referrals, second-level reviews, and status clarifications.

Revenue Integrity & Denial Management

• Coordinate Peer-to-Peer (P2P) reviews with physicians, FCC, and Revenue Cycle teams; maintain appeal documentation.
• Log overturns, track denial status, monitor readmissions, and report denial trends.
• Manage assigned ConnectCare and ADT work queues to support billing operations and CMS compliance.
• Work with Patient Access, Financial Counselors, FCC, and the Business Office to resolve billing issues and non-coverage determinations.

Collaboration & Operational Duties

• Partner with physicians, care managers, nursing, and leadership on patient management.
• Train clinical and administrative staff on UR processes, regulatory updates, and payer rules (MS-DRGs, POA).
• Adhere to FCC communication guidelines across phone, email, and messaging platforms.
• Assist with departmental coverage gaps, maintain data logs, and support quality initiatives.
• Adopt new technologies and AI tools to streamline workflows and reduce friction.

Qualifications

Required

• Licensure: Active, unrestricted RN license (Compact RN license preferred).
• Clinical Experience: Direct clinical experience in ICU, Emergency Department (ED), or Operating Room (OR).
• Quality Improvement: Working knowledge of quality improvement processes.
• Remote Setup & Mobility: High-speed internet connection; willingness to travel for periodic onsite requirements as needed.
• Core Competencies: Clinical judgment, negotiation with payers/physicians, time management, and comfort using AI/tech tools.

Preferred

• 5+ years of Utilization Review (UR) experience.