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Remote Insurance Utilization Review Jobs in California

LIBERTY DENTAL

$74 - $82/hr

We are seeking an experienced Staff Dentist to join our clinical team and play a critical role in supporting our Utilization Management (UM) and Utilization Review (UR) programs. This fully remote ...

Actalent

Remote Genetic Counselor

Mather, CA · Remote

$50 - $60/hr

Perform prospective and retrospective utilization reviews and first-level determination approvals ... Insurance (Voluntary Life & AD&D for the employee and dependents) • Short and long-term ...

New

Actalent

Remote Genetic Counselor

Mather, CA · Remote

$50 - $60/hr

Perform prospective and retrospective utilization reviews and first-level determination approvals ... Insurance (Voluntary Life & AD&D for the employee and dependents) • Short and long-term ...

New

Molina Healthcare

Medical Review Nurse (RN)

Long Beach, CA · Remote

$29.05 - $56.64/hr

Resolves escalated complaints regarding utilization management and long-term services and supports ... insurance commissions, and judicial fair hearings. Reviews medically appropriate clinical ...

New

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All JobsInsurance Utilization Review JobsRemote Insurance Utilization Review JobsRemote Insurance Utilization Review Jobs in California

Remote Insurance Utilization Review information

What is the difference between Remote Insurance Utilization Review vs Remote Claims Reviewer?

AspectRemote Insurance Utilization ReviewRemote Claims Reviewer
CredentialsTypically requires nursing or healthcare-related certifications, such as RN or licensed healthcare professionalUsually requires insurance or claims processing knowledge, sometimes with certifications like CPC or CPC-H
Work EnvironmentRemote, healthcare or insurance company settings, reviewing medical necessity and appropriateness of servicesRemote, insurance companies or third-party administrators, reviewing claims for accuracy and compliance
Industry UsageCommonly used in healthcare insurance to evaluate medical necessityUsed across insurance sectors to process and validate claims

Remote Insurance Utilization Review focuses on assessing the medical necessity of services, often requiring healthcare credentials. Remote Claims Reviewers handle claims processing and validation, emphasizing insurance knowledge. Both roles are remote and industry-specific but differ in their primary responsibilities and required qualifications.

How does a remote insurance utilization review professional collaborate with healthcare providers and insurance companies?

Remote insurance utilization review professionals regularly interact with healthcare providers to gather patient information, clarify treatment plans, and ensure that clinical documentation supports insurance requirements. They also communicate with insurance companies to advocate for patient care, provide necessary justifications, and resolve coverage issues. While the work is done remotely, collaboration typically occurs via secure email, phone calls, and virtual meetings, requiring strong communication and organizational skills to ensure timely and accurate exchange of information.

What is a remote insurance utilization review?

Remote insurance utilization review jobs involve evaluating medical records and treatment plans to determine whether healthcare services are medically necessary and covered by a patient’s insurance plan. Professionals in these roles, often nurses or other healthcare specialists, work from home and communicate with healthcare providers, insurance companies, and patients. Their main goal is to ensure that patients receive appropriate care while also helping insurance companies manage costs and comply with regulations.

What skills and qualifications are needed for a remote insurance utilization review specialist?

To thrive as a Remote Insurance Utilization Review Specialist, you need a strong understanding of medical terminology, clinical guidelines, and insurance policies—usually supported by a nursing or health-related degree and relevant licensure. Familiarity with electronic medical record (EMR) systems, insurance claims platforms, and utilization review software is essential. Strong analytical skills, attention to detail, and effective written communication are crucial soft skills for this role. These competencies ensure accurate case evaluations, compliance with regulations, and clear communication between healthcare providers and insurers.
What are the most commonly searched types of Insurance Utilization Review jobs in California? The most popular types of Insurance Utilization Review jobs in California are:
What are popular job titles related to Remote Insurance Utilization Review jobs in California? For Remote Insurance Utilization Review jobs in California, the most frequently searched job titles are:
What job categories do people searching Remote Insurance Utilization Review jobs in California look for? The top searched job categories for Remote Insurance Utilization Review jobs in California are:
What cities in California are hiring for Remote Insurance Utilization Review jobs? Cities in California with the most Remote Insurance Utilization Review job openings:
Remote Insurance Utilization Review jobs near you
Infographic showing various Remote Insurance Utilization Review job openings in California as of August 2026, with employment types broken down into 94% Full Time, and 6% Contract. Highlights an 100% Remote job distribution.

Utilization Management RN

Dignity Health Management Services

Bakersfield, CA • Remote

$57.37 - $85.33/hr

Full-time

Posted 19 days ago

Job description


Job Summary and Responsibilities

As our UM RN (Utilization Management Registered Nurse), you will be responsible for ensuring the integrity of the adverse determination processes and accuracy of clinical decision-making, as it relates to the application of criteria and composition of compliant denial notices, to review medical records, authorize requested services, and prepare cases for physician review based on medical necessity.
Every day you will partner with both the Pre-Service and In-Patient Utilization Management teams. You will ensure to monitor and assure the appropriateness and medical necessity of care as it relates to quality, continuity, and cost-effectiveness. This involves meticulous review of medical records, application of clinical guidelines, and collaborative communication to facilitate optimal patient care while ensuring compliance and fiscal responsibility.
To be successful in your role, you will strategically ensure the integrity and accuracy of utilization management decisions, meticulously reviewing medical records and applying clinical criteria to determine medical necessity. You will demonstrate exceptional clinical judgment, partner effectively with pre-service and in-patient teams, and maintain rigorous oversight of care appropriateness, quality, continuity, and cost-effectiveness, thereby safeguarding both patient well-being and organizational resources.

As a remote employee, we will provide you with the equipment needed to work from home, including a laptop, docking station, dual monitors, and accessories.

This position is remote with a CA RN license.  PST business hours will be expected.

Potential for on-call, weekend and holiday shifts.

  • Reviews designated requests for referral authorizations either proactively, concurrently or retroactively. Gathering all information needed to make a determination and/or coordinate with the Medical Director as needed.
  • Ensure compliance with turnaround times and accuracy standards are met.
  • Ensure contracted providers are in place when authorizing.
  • Responsible to coordinate with contracting to obtain appropriate contracts as deemed appropriate.
  • Identify cases that require additional case management.
  • Work with appropriate departments and internal staff to coordinate patient care
Job Requirements

Required

  • Three (3) years recent clinical experience
  • Graduate of an accredited RN program
  • Clear and current CA Registered Nurse (RN) license
  • Knowledge of nursing theory and ability to apply or modify as appropriate
  • Knowledge of ICD-10, CPT, HCPCS coding, medical terminology and insurance benefits
  • Knowledge of legal and ethical considerations related to patient information, PHI and HIPPA regulations


Preferred

  • Bachelors of Nursing (BSN) preferred
  • Previous inpatient Utilization Management (UM) experience strongly preferred
  • Experience with MCG strongly preferred
  • EZCap experience a plus
Where You'll Work

The purpose of Dignity Health Management Services Organization (Dignity Health MSO) is to build a system-wide integrated physician-centric, full-service management service organization structure. We offer a menu of management and business services that will leverage economies of scale across provider types and geographies and will lead the effort in developing Dignity Health's Medicaid population health care management pathways. Dignity Health MSO is dedicated to providing quality managed care administrative and clinical services to medical groups, hospitals, health plans and employers with a business objective to excel in coordinating patient care in a manner that supports containing costs while continually improving quality of care and levels of service. Dignity Health MSO accomplishes this by capitalizing on industry-leading technology and integrated administrative systems powered by local human resources that put patient care first.

One Community. One Mission. One California 


Pay Range
$57.37 - $85.33 /hour

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