Remote Ob Rn Jobs in Southgate, MI (NOW HIRING)

This role is a Registered Nurse – Utilization Review/Case Management professional responsible for evaluating healthcare services to ensure medical necessity, appropriate level of care, and cost-effective treatment across inpatient and outpatient settings. The position includes utilization review, appeals handling, care coordination, and discharge planning, while ensuring compliance with regulatory standards.
 

1. Active RN License

• Current, unrestricted Michigan Registered Nurse (RN) license

2. Clinical Experience (2–4 Years)

• Experience in one or more of the following:
• • Acute patient care
  • Case management
  • Discharge planning
  • Utilization review

3. Clinical Knowledge & Decision-Making

• Strong understanding of:
• • Patient care practices
  • Healthcare delivery processes
• Ability to apply clinical judgment in real-world scenarios

4. Utilization Review & Medical Necessity Skills

• Ability to:
• • Evaluate level of care and length of stay
  • Apply clinical guidelines for medical necessity

5. Care Coordination & Discharge Planning

• Ability to:
• • Coordinate care across multiple providers and settings
  • Manage transitions throughout the care continuum

6. Analytical & Critical Thinking

• Ability to:
• • Analyze clinical data and service utilization
  • Identify trends, issues, and opportunities for improvement

7. Regulatory & Compliance Knowledge

• Understanding of:
• • Healthcare regulations (state and federal)
  • Accreditation standards (e.g., NCQA)

8. Communication & Interpersonal Skills

• Strong:
• • Written and verbal communication
  • Provider/member interaction skills
• Ability to educate and collaborate effectively

9. Technical Skills

• Proficiency in:
• • Microsoft Office (Word, Excel, Outlook)
  • Documentation and case management systems

10. Problem-Solving & Issue Resolution

• Ability to:
• • Resolve benefits, eligibility, and authorization issues
  • Navigate complex cases including out-of-network situations

Preferred Qualifications (Listed Last)

• Bachelor’s Degree (Nursing, Allied Health, Business, or related field)
• 1+ year of Managed Care / Health Plan Experience
• Case Management Certification (CCM or similar)

Bottom Line

To succeed in this role, you need a strong clinical RN foundation + analytical thinking + utilization review skills, with preferred experience in managed care and case management certification enhancing your candidacy.

ob Title: RN Review Analyst:

Location: SE Michigan
Job Description:
SUMMARY
Perform prospective, concurrent and retrospective review of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, intensity of service and level of care, including appeal requests initiated by providers, facilities and members.  May establish care plans and coordinate care through the health care continuum including member outreach assessments.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.
1.           Review, research and authorize requests for authorization of elective, direct, ancillary, urgent, emergency, etc. services.  Contact appropriate medical and support personnel to identify and recommend alternative treatment, service levels, length of stays, etc. using approved clinical protocols.
2.           Analyze, research, respond to and prepare documentation related to retrospective review requests and appeals in accordance with local, state and federal regulatory and designated accreditation (e.g. NCQA) standards.
3.           Establish, coordinate and communicate discharge planning needs with appropriate internal and external entities.
4.           Analyze patterns of care associated with disease progression; identify contractual services and organize delivery through appropriate channels.
5.           Research and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, Mental Health, Substance Abuse care coordination, etc.
6.           Identify and document quality of care issues; resolve or route to appropriate area for resolution.
7.           Follow out-of-area/out-of-network services and make recommendations on patient transfer to in-network services and/or alternative plans of care.
8.           Develop and deliver targeted education for provider community related to policies, procedures, benefits, etc.
9.           As needed and in conjunction with Provider Services, may identify and negotiate reimbursement rates for non-contracted providers for services.
10.        Other duties may be assigned based on designated department assignment.
EDUCATION AND EXPERIENCE 
1.           Bachelor’s degree in nursing, allied health, business, or related field preferred.
2.           Two (2) to four (4) years of clinical experience which may include acute patient care, discharge planning, case management, and utilization review, etc.
3.           Demonstrated clinical knowledge and experience relative to patient care and health care delivery processes.
4.           One (1) year health insurance plan experience or managed care environment preferred.
CERTIFICATES, LICENSES, REGISTRATIONS
1.    Registered Nurse with current unrestricted Michigan Registered Nurse license required.
2.    Certification in Case Management may be preferred based upon designated department assignment.
QUALIFICATIONS
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
OTHER SKILLS AND ABILITIES
1.           Excellent written and verbal communication skills.  Excellent customer service and interpersonal skills.
2.           Working knowledge of current industry Microsoft Office Suite PC applications.
3.           Ability to apply clinical criteria/guidelines for medical necessity, setting/level of care and concurrent patient management.
4.           Knowledge of current standard medical procedures/practices and their application as well as current trends and developments in medicine and nursing, alternative care settings and levels of service. .             
5.           Knowledge of applicable accreditation standards, local, state and federal regulations.
6.           Other related skills and/or abilities may be required to perform this job based upon designated department assignment.

Job Description:
Order sent: 6/23/26
Resumes Due: 6/29/26
Max # per supplier: 3
Dept:  Clinical Review
Local candidates only, as there may be an occasional requirement for onsite meetings.
SUMMARY
Perform prospective, concurrent and retrospective review of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, intensity of service and level of care, including appeal requests initiated by providers, facilities and members.  May establish care plans and coordinate care through the health care continuum including member outreach assessments.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.
1. Review, research and authorize requests for authorization of elective, direct, ancillary, urgent, emergency, etc. services.  Contact appropriate medical and support personnel to identify and recommend alternative treatment, service levels, length of stays, etc. using approved clinical protocols.
2. Analyze, research, respond to and prepare documentation related to retrospective review requests and appeals in accordance with local, state and federal regulatory and designated accreditation (e.g. NCQA) standards.
3. Establish, coordinate and communicate discharge planning needs with appropriate internal and external entities.
4. Analyze patterns of care associated with disease progression; identify contractual services and organize delivery through appropriate channels.
5. Research and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, Mental Health, Substance Abuse care coordination, etc.
6. Identify and document quality of care issues; resolve or route to appropriate area for resolution.
7. Follow out-of-area/out-of-network services and make recommendations on patient transfer to in-network services and/or alternative plans of care.
8. Develop and deliver targeted education for provider community related to policies, procedures, benefits, etc.
9. As needed and in conjunction with Provider Services, may identify and negotiate reimbursement rates for non-contracted providers for services.
10. Other duties may be assigned based on designated department assignment.
EDUCATION AND EXPERIENCE 
1. Bachelor’s degree in nursing, allied health, business, or related field preferred.
2. Two (2) to four (4) years of clinical experience which may include acute patient care, discharge planning, case management, and utilization review, etc.
3. Demonstrated clinical knowledge and experience relative to patient care and health care delivery processes.
4. One (1) year health insurance plan experience or managed care environment preferred.
CERTIFICATES, LICENSES, REGISTRATIONS
1.    Registered Nurse with current unrestricted Michigan Registered Nurse license required.
2.    Certification in Case Management may be preferred based upon designated department assignment.
QUALIFICATIONS
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
OTHER SKILLS AND ABILITIES
1. Excellent written and verbal communication skills.  Excellent customer service and interpersonal skills.
2. Working knowledge of current industry Microsoft Office Suite PC applications.
3. Ability to apply clinical criteria/guidelines for medical necessity, setting/level of care and concurrent patient management.
4. Knowledge of current standard medical procedures/practices and their application as well as current trends and developments in medicine and nursing, alternative care settings and levels of service. .
5. Knowledge of applicable accreditation standards, local, state and federal regulations.
6. Other related skills and/or abilities may be required to perform this job based upon designated department assignment.