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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 ...

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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 89% Full Time, 5% Part Time, and 6% Contract. Highlights an 100% Remote job distribution.

RN Supervisor UM Prior Auth

Dignity Health Medical Foundation

Rancho Cordova, CA • On-site, Remote

$53.46 - $79.52/hr

Other

Re-posted 2 days ago

Job description

Where You'll Work
Dignity Health Medical Foundation, established in 1993, is a California nonprofit public benefit corporation with care centers throughout California. Dignity Health Medical Foundation is an affiliate of Dignity Health - one of the largest health systems in the nation - with hospitals and care centers in California, Arizona and Nevada. Today, Dignity Health Medical Foundation works hand-in-hand with physicians and providers throughout California to provide comprehensive health care services to the many communities we serve. As Dignity Health Medical Foundation continues to grow and establish new premier care centers, we provide increasing support and investment in the latest technologies, finest physicians and state-of-the-art medical facilities. Our 130+ clinics across the state of California deliver high-quality, patient-centric care with an emphasis on humankindness. Through affiliations with Dignity Health hospitals, along with our joint ventures and partnerships, we offer a robust, state-of-the-art health care delivery system in the communities we serve .We strive to create purposeful work settings where staff can provide great care, while advancing in knowledge and experience through challenging work assignments and stimulating relationships. Our staff is well-trained and highly skilled, qualities that are vital to maintaining excellence in care and service.
One Community. One Mission. One California
Job Summary and Responsibilities
As our Supervisor of Utilization Management (UM), under the guidance and supervision of the department Manager/Director, you will be responsible and accountable for coordination of services for Mercy Medical Group and Woodland Clinic Medical Group through an interdisciplinary process that provides a clinical and financial approach through the continuum of care.
Every day you will promote the quality and cost effectiveness of medical care by ensuring department staff are applying clinical acumen and the appropriate application of policies and guidelines to Managed Care prior authorization referral requests. Under general supervision, this position is responsible for coordinating the daily operations of the UM Pre-Authorization team in order to ensure requests are processed in a consistent and timely manner while observing regulatory guidelines.
To be successful in this role, you will have a strong knowledge of Utilization Management, strong leadership skills, and a passion for high-quality patient care.
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 primarily work-from-home within driving distance of Sacramento, CA, as there may be occasional onsite meetings.
This position will work rotating weekends.
  • Responsible for day to day operations of the Pre-Authorization team to include timely response and appropriate evaluation of referral reviews, correct selection of criteria, accurate prep to the UM Physician reviewer when indicated, timely verbal and written documentation, and completion of the file.
  • Ensures adequate staffing and assignments and adjusts workflow as needed to meet department goals. Manages team schedule including requests for time off and assurance of coverage during physician office hours.
  • Organizes, structures, and chairs a minimum of one pre-authorization meeting per month, including other staff as appropriate.
  • Motivates and coaches staff to include new-hire training, problem solving, and special projects. Assists manager with performance activities to include monitoring, coaching, educating, and providing feedback to team.
  • Ensures UM Physicians are provided the relevant information needed to accurately review a referral. Fosters the relationship between the Pre- Authorization team and the Medical Director and Physician Reviewers.
  • Tracks cost savings from activities over time to evaluate success of programs. Maintains or removes programs based on organization and department goals. Develops reports for leadership as required.

Job Requirements
Required:
  • Five (5) years clinical experience
  • Three (3) years Utilization experience in health plan/UM operations, acute or subacute utilization review
  • Bachelors degree, or equivalent experience
  • Clear and current CA Registered Nurse (RN) license
  • Ability to demonstrate leadership and management skills
  • Knowledge of all applicable federal and state regulations as well as accreditation standards
  • Demonstrates a working knowledge of Utilization Management, UM review processes, and regulatory requirements
  • Must have the ability to monitor, compile, report and analyze data/statistics
  • Requires excellent human relations, interpersonal and oral/written communication skills
  • Able to recognize and address the needs and concerns of customers
  • Ability to interact with all levels of the organization as well as with external contacts
  • Requires good knowledge and skills with Microsoft Office (ie: Word and Excel) and other computer information systems and applications

Preferred:
  • Seven (7) years UM experience with Charge/Lead/Supervisory/Management experience in Utilization Management department preferred
  • Previous prior authorization experience strongly preferred
  • Managed care experience preferred
  • Experience working with health plan auditors preferred
  • Working knowledge of InterQual preferred
  • Knowledgeable of NCQA and ICE preferred

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