Entry Level Remote Rn Jobs in Niles, IL (NOW HIRING)

We are seeking experienced Clinical Review Nurses to join a growing Utilization Management team focused on concurrent clinical reviews and post-acute care oversight.

In this role, you will review inpatient cases to determine medical necessity, appropriate level of care, and continued-stay needs. You will use clinical judgment, established criteria, regulatory requirements, and member benefit information to support appropriate, high-quality, and cost-effective care.

This is an excellent opportunity for a clinically experienced nurse who enjoys analyzing complex cases, collaborating with providers and multidisciplinary teams, and helping members transition to the most appropriate level of care.
Target Start Date: September 28, 2026
Work Arrangement: 100% Remote
Schedule: Monday–Friday, 8am PST-5pm PST with weekend/holiday rotation
Preferred Time Zones: Central, Mountain, or Pacific
Business Area: Medicare

Pay: $36-41/hr based on qualifications

Key Responsibilities

• Perform concurrent medical necessity and clinical reviews for inpatient services using established clinical criteria and regulatory guidelines.
• Review assigned cases and prioritize new requests, continued-stay reviews, time-sensitive discharges, and cases approaching regulatory or internal turnaround-time requirements.
• Evaluate the member's clinical status, treatment plan, functional needs, progress, discharge barriers, and appropriate level of care.
• Apply clinical criteria, benefit requirements, and payer guidelines to determine whether the requested level of care remains medically appropriate.
• Complete authorization activities and accurately document clinical findings, rationale, criteria applied, communications, decisions, and next review dates.
• Identify complex cases or cases that do not clearly meet criteria and escalate them appropriately for Medical Director review.
• Evaluate opportunities for transition to lower or alternative levels of care, including SNF, inpatient rehabilitation, LTACH, home health, and other post-acute services.
• Collaborate with providers, facilities, case managers, authorization teams, and internal departments to obtain clinical information and support timely transitions of care.
• Participate in rounds, huddles, and case discussions involving complex cases, discharge barriers, avoidable delays, and readmission risks.
• Reassess active cases as new clinical information becomes available and monitor progress toward discharge goals.
• Identify trends such as prolonged stays, repeat admissions, authorization delays, or gaps in transitions of care and escalate opportunities for quality improvement.
• Ensure all reviews due during the day are completed and that urgent cases, follow-ups, and outstanding clinical information are appropriately addressed.
• Maintain compliance with organizational policies, regulatory requirements, and applicable Medicare guidelines.

Required Qualifications

• Graduate of an accredited school of nursing or Bachelor's degree in Nursing.
• Active RN state license required.
• 2+ years of acute care experience required.
• 2–4 years of related clinical experience.
• Direct patient-care experience in an acute inpatient setting is required.
• Strong clinical judgment and critical-thinking skills.
• Ability to analyze complex clinical situations and apply utilization management criteria and guidelines.
• Ability to manage competing priorities and work effectively in a fast-paced environment.
• Strong written and verbal communication skills.
• Ability to clearly communicate with providers, care teams, and insurance representatives.
• Strong documentation and organizational skills.
• Compact RN licensure.
• Experience with utilization management processes.
• Experience using medical necessity criteria/tools such as InterQual or MCG.
• Knowledge of Medicare and Medicaid regulations.
• Familiarity with CMS guidelines, payer policies, authorization processes, and healthcare compliance standards.
• Experience with concurrent review, utilization management, discharge planning, or post-acute care coordination.

If you are interested in the opportunity, apply today with Abbey from A-Line!