Lead Utilization Review Nurse (RN)
Position Type: Full-Time / Direct Hire
Work Arrangement: 100% Remote (Nationwide)
Schedule: Monday – Friday (Standard Business Hours, with potential for rotating weekend coverage)
Salary Range: $81,952.00 – $110,240.00 / year (Commensurate with experience)
Position Overview
We are seeking an experienced and detail-oriented Lead Utilization Review Registered Nurse (RN) to perform daily medical necessity evaluations, manage denial workflows, and optimize revenue integrity across inpatient and observation settings. In this high-impact remote role, you will leverage clinical criteria sets, partner with physicians and interdisciplinary care teams, and ensure commercial payer submissions meet strict compliance and timing standards.
Key Responsibilities
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Medical Necessity & Level of Care Reviews: Perform daily clinical evaluations for admissions, continued stays, and status determinations (inpatient vs. observation) using approved clinical criteria; submit reviews to commercial payers within 1 business day.
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Resource Utilization & Physician Referrals: Proactively identify over- or under-utilization using clinical triggers (diagnoses, cost, complications) and initiate timely referrals for second-level physician advisor reviews.
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Discharge Planning Support: Review clinical charts to identify discharge needs early and collaborate with care teams and liaisons to facilitate safe, timely post-discharge transitions.
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Denials & Appeals Management: Coordinate appeal workflows with liaisons, Revenue Cycle, and Financial Clearance teams; log updates, track overturned days, monitor denial trends, and analyze readmission rates.
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Revenue Integrity & Work Queue Management: Maintain case management work queues in Epic/EHR (including ConnectCare and ADT) to ensure accurate statistical data entry and seamless documentation.
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Interdisciplinary Collaboration: Partner with physicians, bedside nurses, coding specialists, and patient access teams to resolve third-party billing barriers, clarify documentation, and adjust multidisciplinary care plans.
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Teamwork & Continuous Improvement: Provide peer coverage, participate in departmental process improvement initiatives, and contribute to hospital committees and task forces.
Requirements & Qualifications
Must-Have Qualifications:
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Licensure: Active, unrestricted Registered Nurse (RN) license.
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Clinical Experience: Minimum of 5 years of RN nursing experience in an acute care setting.
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Education: Minimum of an Associate Degree in Nursing (ADN).
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Technical Skills: Strong computer proficiency, including EHR experience (Epic preferred) and database/spreadsheet analysis.
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Core Competencies: Excellent clinical assessment skills, strong multi-tasking abilities, and effective written and verbal communication.
Preferred Qualifications:
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Education: Bachelor of Science in Nursing (BSN).
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Domain Experience: Prior working experience in utilization review, case management, or discharge planning.
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Regulatory Knowledge: Practical working knowledge of medical necessity criteria sets (InterQual/MCG), MS-DRGs, and Present on Admission (POA) guidelines.
*We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state, and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA).
*As a job position within our Care Management division, a successful completion of a background check may be required as a condition of employment. This requirement is directly related to essential job functions including but not limited to: accessing financial and confidential information, access and handling of patient medical records, providing medical care inside a patient’s residential address, driving, prescription and other drug access and administration, and working with vulnerable populations, such as, minors, elderly and those with physical or mental disabilities. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.
