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Remote Hca Utilization Review Jobs in Nevada (NOW HIRING)

Abbott

Distribution Field Manager - West

Las Vegas, NV · Remote

$86K - $173K/yr

... utilization in current accounts. Understands and assesses customer's business issues and objectives ... This is a remote sales opportunity and will cover the West Region (AZ/NV/CA/ID/OR/WA) estimated 70 ...

Abbott

Distribution Field Manager - West

Las Vegas, NV · Remote

$86K - $173K/yr

... utilization in current accounts. Understands and assesses customer's business issues and objectives ... This is a remote sales opportunity and will cover the West Region (AZ/NV/CA/ID/OR/WA) estimated 70 ...

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Remote Hca Utilization Review information

What is the difference between Remote Hca Utilization Review vs Remote Hca Case Manager?

AspectRemote Hca Utilization ReviewRemote Hca Case Manager
CredentialsTypically requires healthcare-related certifications, such as RN or licensed healthcare professionalOften requires RN, social work, or case management certifications
Work EnvironmentPrimarily reviewing medical necessity and insurance coverage remotelyManaging patient cases, coordinating care, and discharge planning remotely
Employer & Industry UsageUsed by health insurance companies, healthcare providers, and utilization review organizationsEmployed by hospitals, insurance companies, and healthcare organizations

Remote Hca Utilization Review focuses on assessing medical necessity and insurance coverage, while Remote Hca Case Managers handle patient care coordination and discharge planning. Both roles require healthcare credentials and are integral to healthcare management, but they differ in daily responsibilities and focus areas.

How do I get into a remote HCA utilization review?

To become a remote HCA utilization review specialist, candidates typically need a healthcare background such as nursing or medical coding, along with knowledge of insurance policies and medical terminology. Relevant certifications like Certified Professional Coder (CPC) or Certified Medical Reimbursement Specialist (CMRS) can improve job prospects. Employers often require prior experience in medical review or utilization management and proficiency with electronic health record (EHR) systems, with many roles offering flexible or remote schedules.

Is remote HCA utilization review work from home?

Remote HCA utilization review jobs are often performed from home, allowing reviewers to assess healthcare claims and authorizations remotely. These roles typically require familiarity with healthcare software, strong communication skills, and adherence to confidentiality standards. Many employers offer flexible or fully remote schedules for this position.

What are popular job titles related to Remote Hca Utilization Review jobs in Nevada?

For Remote Hca Utilization Review jobs in Nevada, the most frequently searched job titles are:

What job categories do people searching Remote Hca Utilization Review jobs in Nevada look for?

The top searched job categories for Remote Hca Utilization Review jobs in Nevada are:

What cities in Nevada are hiring for Remote Hca Utilization Review jobs?

Cities in Nevada with the most Remote Hca Utilization Review job openings:

Remote Hca Utilization Review jobs near you
Infographic showing various Remote Hca Utilization Review job openings in Nevada as of August 2026, with employment types broken down into 90% Full Time, and 10% Contract. Highlights an 100% Remote job distribution.

Medical Director, Utilization Management (Commercial & MA)

HJ Staffing

Henderson, NV • On-site, Remote

Full-time

Medical

Posted 29 days ago

Job description

We are seeking a Medical Director of Utilization Management to lead and support the clinical integrity of our utilization management (UM) functions, with a primary focus on inpatient and post-acute care reviews.

In this role, you will ensure timely, consistent, and appropriate care determinations for Commercial and Medicare Advantage members. By leveraging evidence-based practices, CMS regulations, and health plan benefit structures, you will evaluate the medical necessity of care, participate in peer-to-peer consultations, and collaborate with multidisciplinary teams to drive optimal clinical outcomes, regulatory compliance, and cost efficiency.

Duration: August 10, 2026 - February 10, 2027

Location: Henderson, NV (100% Fully Remote Opportunity)

Reporting To: Chief Medical Officer

Start Date: Immediate Need

Key Responsibilities
  • Utilization Review & Medical Necessity: Conduct timely medical necessity determinations for inpatient admissions, continued stays, and post-acute care settings (SNF, IRF, LTACH, Home Health) for Commercial and Medicare Advantage populations.
  • Evidence-Based Evaluation: Apply nationally recognized guidelines (MCG, InterQual), CMS coverage criteria, and health plan policies to ensure appropriate level-of-care determinations.
  • Complex Case Escalation: Serve as the lead physician reviewer for complex, high-risk, or potentially adverse UM cases requiring clinical judgment.
  • Peer-to-Peer Engagement: Conduct peer-to-peer discussions with attending and treating physicians to clarify documentation, discuss options, and align on appropriate care plans.
  • Cross-Functional Collaboration: Partner with Care Management and UM teams to identify utilization trends, reduce avoidable readmissions/extended stays, and streamline care transitions.
  • Policy & Quality Support: Offer clinical expertise to support quality improvement initiatives, regulatory audit preparedness (CMS/NCQA), policy development, and UM committee activities.
  • Documentation & Compliance: Maintain precise, compliant, and timely documentation of all reviews and rationales in accordance with federal, state, and organizational guidelines.
Must-Have Qualifications
  • Education & Licensure: Active M.D. or D.O. degree with an active, unrestricted medical license in good standing (in state of residence).
  • Board Certification: Current Board Certification in an appropriate medical specialty.
  • Clinical & Leadership Experience: Minimum of 5 years of clinical practice, including at least 3 years of direct experience in utilization management, physician review, or medical leadership within a managed care or health plan setting.
  • Population Expertise: Demonstrated physician-level experience supporting Commercial and/or Medicare Advantage lines of business.
What Will Make You Successful
  • Criteria Proficiency: Advanced expertise with MCG guidelines and strong working knowledge of InterQual and CMS criteria.
  • Regulatory Knowledge: Deep understanding of Medicare Advantage regulations, Commercial health plan benefit structures, and state/federal UM mandates.
  • Technical Skills: Experience navigating medical management platforms, enterprise applications, and Microsoft Office products.
  • Communication & Negotiation: Exceptional written and oral communication skills, with a proven ability to handle delicate peer-to-peer discussions and articulate complex clinical rationales clearly.
  • Analytical Mindset: Strong problem-solving abilities, attention to detail, and a data-driven approach to identifying utilization trends and quality gaps.
Preferred Qualifications
  • Master's degree in Public Health, Business Administration, or Health Administration (MPH, MBA, or MHA).
  • Certification by the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP).
Why Apply?

This is a 100% remote, high-impact contract opportunity starting immediately, offering you the flexibility of working from home while managing key clinical determinations for a dynamic health plan environment.

Employment Type: FULL_TIME

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