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Remote Insurance Utilization Review Jobs (NOW HIRING)

VIVA USA INC

Utilization Review Nurse

Nashville, TN · On-site +1

$37.22 - $42.22/hr

... of insurance industry, medical coding (CPT/HCPCS/ICD-10), and overall claims process a plus ... Remote Contract to Hire VIVA is an equal opportunity employer. All qualified applicants have an ...

Umpqua Health

Utilization Review Nurse

Roseburg, OR · On-site +1

$85K - $105.34K/yr

UTILIZATION REVIEW NURSE REMOTE, ability to travel to 3031 NE STEPHENS ST. ROSEBURG, OR 97470, as ... Medical, dental, and vision insurance * 401(k) with company match (fully vested immediately)

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How much do remote insurance utilization review jobs pay per hour?

As of Jun 3, 2026, the average hourly pay for remote insurance utilization review in the United States is $42.28, according to ZipRecruiter salary data. Most workers in this role earn between $33.41 and $48.56 per hour, depending on experience, location, and employer.

What are the key skills and qualifications needed to thrive as a Remote Insurance Utilization Review Specialist, and why are they important?

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.

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 are remote insurance utilization review jobs?

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 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.

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What states have the most Remote Insurance Utilization Review jobs? States with the most job openings for Remote Insurance Utilization Review jobs include:
What job categories do people searching Remote Insurance Utilization Review jobs look for? The top searched job categories for Remote Insurance Utilization Review jobs are:
Remote Insurance Utilization Review jobs near you
Utilization Review Nurse - Remote

Utilization Review Nurse - Remote

Martin's Point Health Care

Portland, ME • On-site, Remote

Full-time

Posted 9 days ago

Martin’s Point Health Care rating

7.4

Company rating: 7.4 out of 10

Based on 6 frontline employees who took The Breakroom Quiz

Job description

Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.
Position Summary
The Utilization Review Nurse works as is responsible for ensuring the receipt of high quality, cost efficient medical outcomes for those enrollees with a need for inpatient/ outpatient authorizations. This position receives and reviews prior authorization requests for specific inpatient and outpatient medical services, notification of emergent hospital admissions, completes inpatient concurrent review, establishes discharge plans, coordinates transitions of care to lower/higher levels of care, makes referrals for care management programs, and performs medical necessity reviews for retrospective authorization requests as well as claims disputes.
The Utilization Review Nurse will use appropriate governmental policies as well as specified clinical guidelines/ criteria to guide medical necessity reviews and will use effective relationship management, coordination of services, resource management, education, patient advocacy and related interventions to ensure members receive the appropriate level of care, prevent or reduce hospital admissions where appropriate.
Job Description
Key Outcomes:
  • Review prior authorization requests (prior authorization, concurrent review, and retrospective review) for medical necessity referring to Medical Director as needed for additional expertise and review.
  • Utilize evidenced-based criteria, governmental policies, and internal guidelines for medical necessity reviews.
  • Manage the review of medical claims disputes, records, and authorizations for billing, coding, and other compliance or reimbursement related issues
  • Collaborates with other members of the team, the MPHC Medical Directors, healthcare providers, and members to promote effective utilization of resources. This collaboration includes timely communications with in and out of network hospitals, post-acute care facilities, other providers, and internal departments to authorize services, establish discharge plans, assist to coordinate effective, efficient transitions of care.
  • Coordinates referrals to Care Management, as appropriate.
  • Manages health care within the benefits structures per line of business and performs functions within compliance, contractual and accreditation regulations, e.g. Department of Defense, Centers for Medicaid and Medicare, NCQA, Employer contracts and state insurance regulations, as applicable. Maintains knowledge of applicable regulatory guidelines.
  • Completes all documentation of reviews and decisions, in appropriate systems, according to process/ compliance requirements and within timeliness standards.
  • Participates as a member of an interdisciplinary team in the Health Management Department
  • May be responsible for maintaining a caseload for concurrent cases/ assisting in caseload coverage for the team
  • Establishes and maintains strong professional relationships with community providers.
  • Acts as a liaison to ensure the member is receiving the appropriate level of care at the appropriate place and time
  • Mentors new staff as assigned.
  • Meets or exceeds department quality audit scores.
  • Meets or exceeds department productivity.
  • Assists in creation and updating of department policies and procedures.
  • Participates in quality initiatives, committees, work groups, projects, and process improvements that reinforce best practice medical management programming and offerings.
  • Participates in the review and analysis of population data and metrics to inform development of programs and improved health outcomes.
  • Demonstrates flexibility and agility in working in a fast-paced, team-oriented environment, able to multi-task from one case type to another.
  • Assumes extra duties as assigned based on business needs, including weekend rotations

Education/Experience:
  • 3+ years of clinical nursing experience as an RN, preferably in a hospital setting
  • 2+ years of utilization management experience in a health plan UM department

Required License(s) and/or Certification(s):
  • Compact RN License
  • Certification in managed care nursing or care management desired (CMCN or CCM)
  • Coding/CPC desired

Skills/Knowledge/Competencies (Behaviors):
  • Proficiency in conducting prospective, concurrent, and retrospective reviews using standardized criteria and guidelines like MCG
  • Ability to review and interpret medical records, treatment plans, and clinical documentation, with a keen eye for detail and compliance with healthcare standards
  • Thorough understanding of healthcare policies, insurance guidelines, and regulatory standards (e.g., Medicare, NCQA, TRICARE)
  • Familiarity with coding systems like ICD-10 and CPT
  • Technical savvy and ability to navigate multiple systems and screens while working cases
    Demonstrates an understanding of and alignment with Martin's Point Values.
  • Maintains current licensure and practices within scope of license for current state of residence.
  • Maintains knowledge of Scope of Nursing Practice in states where licensed.
  • Maintains contemporary knowledge of evidence-based guidelines and applies them consistently and appropriately.
  • Ability to analyze data metrics, outcomes, and trends.
  • Excellent interpersonal, verbal, and written communication skills.
  • Critical thinking: can identify root causes and understands coordination of medical and clinical information.
  • Ability to prioritize time and tasks efficiently and effectively.
  • Ability to manage multiple demands.
  • Ability to function independently.
  • Computer proficiency in Microsoft Office products including Word, Excel, and Outlook.

This position is not eligible for immigration sponsorship.
We are an equal opportunity/affirmative action employer.
Martin's Point complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact jobinquiries@martinspoint.org
Do you have a question about careers at Martin's Point Health Care? Contact us at: jobinquiries@martinspoint.org

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