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Remote Rn Utilization Review Nurse Jobs in Virginia

Aetna

Case Manager RN

Charlottesville, VA · Remote

Click here to review the benefits associated with this position. Aetna is an equal opportunity ... utilization of available resources, optimal member functioning, and cost-effective outcomes.

Sentara Healthcare

Nurse Case Manager

Newport News, VA · On-site +1

Position is remote but does require in person face-to-face assessments multiple times throughout ... Virginia or Compact RN License (Required) Experience * 3 years experience in Nursing (Required)

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Remote Rn Utilization Review Nurse information

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$41

$68

How much do remote rn utilization review nurse jobs pay per hour?

As of Jun 27, 2026, the average hourly pay for remote rn utilization review nurse in Virginia is $41.92, according to ZipRecruiter salary data. Most workers in this role earn between $33.12 and $48.12 per hour, depending on experience, location, and employer.

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

AspectRemote Rn Utilization Review NurseRemote Rn Case Manager
CertificationsRN license, possibly UR or CCM certificationRN license, CCM or other case management certification
Work EnvironmentReviewing medical records, insurance guidelines, and authorizationsCoordinating patient care, discharge planning, and resource management
Employer & Industry UsageHealth insurance companies, third-party administratorsHospitals, health plans, healthcare providers

Remote Rn Utilization Review Nurses primarily evaluate medical necessity for insurance approvals, focusing on documentation and guidelines. In contrast, Remote Rn Case Managers coordinate patient care, discharge planning, and resource allocation. Both roles require RN licensure and related certifications but differ in daily tasks and work focus.

What is a Remote RN Utilization Review Nurse?

A Remote RN Utilization Review Nurse is a registered nurse who evaluates medical records and healthcare services from a remote location to ensure that patients receive appropriate, necessary, and cost-effective care. They review treatment plans, check for compliance with insurance and healthcare guidelines, and often work with healthcare providers, insurance companies, and patients to coordinate care. This role typically involves assessing the medical necessity of procedures, authorizing services, and helping prevent unnecessary treatments or hospitalizations.

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

To thrive as a Remote RN Utilization Review Nurse, you need an active RN license, strong clinical knowledge, and experience in case management or utilization review. Proficiency with healthcare review software, electronic health records (EHRs), and familiarity with insurance guidelines or regulatory requirements is vital. Excellent communication, critical thinking, and time management skills distinguish top performers in remote settings. These skills enable nurses to make accurate, timely decisions about patient care while ensuring compliance and efficient resource utilization.

What are some common challenges faced by Remote RN Utilization Review Nurses, and how can they be addressed?

Remote RN Utilization Review Nurses often encounter challenges such as managing large caseloads, maintaining effective communication with interdisciplinary teams, and staying updated with ever-changing insurance guidelines. Balancing productivity expectations while ensuring thorough case reviews can be demanding. To address these challenges, nurses can utilize robust organizational tools, participate in ongoing training sessions, and leverage regular virtual meetings to stay connected with colleagues and supervisors, ensuring both efficiency and high-quality patient care.
What are the most commonly searched types of Rn Utilization Review Nurse jobs in Virginia? The most popular types of Rn Utilization Review Nurse jobs in Virginia are:
What are popular job titles related to Remote Rn Utilization Review Nurse jobs in Virginia? For Remote Rn Utilization Review Nurse jobs in Virginia, the most frequently searched job titles are:
What job categories do people searching Remote Rn Utilization Review Nurse jobs in Virginia look for? The top searched job categories for Remote Rn Utilization Review Nurse jobs in Virginia are:
What cities in Virginia are hiring for Remote Rn Utilization Review Nurse jobs? Cities in Virginia with the most Remote Rn Utilization Review Nurse job openings:
Remote Rn Utilization Review Nurse jobs near you
Infographic showing various Remote Rn Utilization Review Nurse job openings in Virginia as of June 2026, with employment types broken down into 78% Full Time, 13% Part Time, 8% Contract, and 1% Nights. Highlights an 90% Physical, 2% Hybrid, and 8% Remote job distribution, with an average salary of $87,192 per year, or $41.9 per hour.
SIU Nurse Auditor, RN, CPC (Full-time, Remote)

SIU Nurse Auditor, RN, CPC (Full-time, Remote)

Integrity Management Services, Inc.

Alexandria, VA • Remote

Other

Posted 23 days ago

Job description

Job Title: Clinical Nurse Auditor - Payment Integrity

Job Summary
We are seeking an experienced Clinical Nurse Auditor to join our Payment Integrity team. In this role, you will leverage your clinical expertise, medical coding proficiency, and auditing skills to identify, monitor, and analyze unusual utilization patterns and potential fraud by healthcare providers. You will conduct prepayment claims reviews, post-payment audits, and comprehensive provider record reviews to ensure accurate billing, compliance with payer regulations, and integrity in reimbursement practices. This position requires a Registered Nurse (RN) with coding certifications such as CPC (Certified Professional Coder), CIC (Certified Inpatient Coder), CDI (Clinical Documentation Improvement), or a similar credential, through AAPC or AHIMA. Knowledge of commercial insurance plans, Medicare, and Medicaid programs is essential.

How You Will Make an Impact

  • Investigations and Audits: Conduct in-depth medical reviews through prepayment claims review and post-payment auditing to identify potential over-utilization or fraudulent activities.
  • Tool and Policy Development: Assist in the creation of audit tools, policies, procedures, and educational materials to enhance audit effectiveness and maintain high standards in payment integrity.
  • Cross-Departmental Collaboration: Serve as a liaison with service operations and other departments to provide status updates on claims reviews and coordinate actions as needed.
  • Data Analysis and Trending: Analyze performance data to identify patterns and trends, collaborate with service operations to address process improvements, and recommend modifications to medical policy.
  • Fraud Detection Support: Support fraud investigators with medical review expertise to detect and address fraudulent activities.
  • Mentorship: Act as a resource and mentor to other nurse auditors, supporting their professional growth and development in audit practices.

Requirements

Qualifications

  • Education:
    • Minimum Associate's Degree in Nursing required;
  • Licensure & Certification:
    • Current, unrestricted Registered Nurse (RN) license in applicable state(s).
    • Certification in medical coding from AAPC or AHIMA (e.g., CPC, CIC, CDI, or equivalent) is highly preferred.
  • Experience:
    • Minimum 5 years of clinical nursing experience, preferably with exposure to hospital bill auditing or defense auditing.
    • Strong knowledge of provider manuals, reimbursement policies, and medical policy guidelines.
    • Prior experience with healthcare fraud investigation and auditing is highly preferred.
  • Skills:
    • Proficiency in CPT/HCPCS and ICD-10 coding, with a strong foundation in auditing, accounting, and control principles.
    • Analytical and problem-solving skills with a keen attention to detail.
    • Exceptional written and verbal communication skills for clear and effective reporting and provider engagement.
    • Strong proficiency in Microsoft Office and familiarity with audit tracking systems.

Preferred Traits

  • Meticulous, organized, and objective in analyzing claims and documentation.
  • Ethical and responsible, with a commitment to supporting the integrity of healthcare billing and reimbursement.
  • Able to work independently, stay current with rapidly changing healthcare regulations, and thrive in a fast-paced environment.

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