Virtual Utilization Review Nurse - 259398

Role: Remote Utilization Review (UR) Nurse

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.
• 10% Weekend Differential: For all weekend hours worked.
• Stackable Rate: 20% total differential for working weekend evening shifts.

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.
• InterQual system experience.
• Pediatric nursing experience.