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Remote Utilization Management Nurse Jobs in Puerto Rico

OncoHealth

Case Review Representative

Guaynabo, PR · On-site +1

$13 - $15/hr

Remote/hybrid work experience preferred * A minimum of 2 years of healthcare related administrative ... Our Current Solutions Through the use of OncoHealth's utilization management system, OneUM , our ...

LifeLink

Remote Administrator on Call PR

Guaynabo, PR · On-site +1

... management, allocation, recovery, and overall coordination of donor-related actions. The Remote ... Works closely with the Referral Coordinator (RC) in the utilization of available staff and ...

OncoHealth

Case Review Specialist - PR

Guaynabo, PR · On-site +1

Remote/hybrid experience preferred * A minimum of 2-4 years' administrative experience and/or ... Our Current Solutions Through the use of OncoHealth's utilization management system, OneUM , our ...

Veterans Health Administration

$46K - $119K/yr

... utilization. RN integrates outpatient nursing knowledge, skills, abilities, and judgment and is self-directed in goal setting for managing complex PACT situations. Duties include but are not limited ...

Abarca Health

Pharmacy Rebates Analyst

San Juan, PR · Remote

You will proactively evaluate utilization and rebate data to identify opportunities to optimize ... Experience within the pharmacy benefit management or healthcare Industry. * Experience with ...

RelateCare

$11/hr

We are a multidisciplinary team of nurses, contact management specialists and technologists who ... Remote

RelateCare

$11/hr

We are a multidisciplinary team of nurses, contact management specialists and technologists who ... Remote

All JobsUtilization Management Nurse JobsRemote Utilization Management Nurse JobsRemote Utilization Management Nurse Jobs in Puerto Rico

Remote Utilization Management Nurse information

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

AspectRemote Utilization Management NurseRemote Case Manager
CredentialsRN license, certifications like CCM or ANCCRN license, certifications like CCM or similar
Work EnvironmentHealthcare organizations, insurance companies, telehealthInsurance companies, healthcare providers, telehealth
Job FocusReviewing medical necessity, authorizations, and utilizationCoordinating patient care, discharge planning, resource management

Both roles require RN licensure and similar certifications, often working remotely within healthcare or insurance settings. The main difference lies in focus: Utilization Management Nurses primarily review medical necessity and authorization requests, while Case Managers coordinate patient care and discharge planning. Understanding these distinctions helps job seekers identify the role that best matches their skills and career goals.

What is a Remote Utilization Management Nurse?

A Remote Utilization Management Nurse is a registered nurse who works from a remote location, such as their home, to review patient medical records and determine the necessity, appropriateness, and efficiency of healthcare services. They collaborate with healthcare providers and insurance companies to ensure that patients receive appropriate care while managing costs. Their main responsibilities include reviewing clinical documentation, conducting pre-authorization reviews, and ensuring compliance with healthcare regulations and insurance guidelines.

What Does a Remote Utilization Management Nurse Do?

As a remote utilization management nurse, you work from home to perform a variety of duties and responsibilities, such as corresponding with and interviewing physicians, modifying patient treatment plans, analyzing investigation information, and auditing patient records. As a UM nurse, you may also deal with other clinical tasks, referrals, authorizations, and reviews. You usually work for insurance companies and healthcare providers to help to determine if patients should receive authorization for needed treatments or for those that they already receive. In some cases, you may monitor processes to ensure that hospital patients are getting what they need during their stay.

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

To thrive as a Remote Utilization Management Nurse, you need a valid RN license, clinical experience (often in acute care), and a solid understanding of utilization review and healthcare regulations. Familiarity with case management software, electronic medical records (EMRs), and tools like InterQual or Milliman Care Guidelines is typically required. Strong analytical skills, attention to detail, and effective written and verbal communication are essential soft skills for successful remote collaboration and decision-making. These skills ensure accurate assessments, compliance with standards, and the delivery of cost-effective, quality patient care from a remote setting.

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

Remote Utilization Management Nurses often face challenges such as maintaining effective communication with interdisciplinary teams, staying updated on changing insurance guidelines, and managing a high volume of case reviews. To address these issues, it's helpful to establish regular virtual check-ins with team members, utilize digital tools for efficient documentation, and participate in ongoing training on payer requirements. Developing strong organizational skills and proactively seeking clarification on complex cases can also contribute to success in this role.
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What cities in Puerto Rico are hiring for Remote Utilization Management Nurse jobs? Cities in Puerto Rico with the most Remote Utilization Management Nurse job openings:
Remote Utilization Management Nurse jobs near you
Infographic showing various Remote Utilization Management Nurse job openings in Puerto Rico as of June 2026, with employment types broken down into 5% As Needed, 53% Full Time, 10% Part Time, and 32% Contract. Highlights an 52% Physical, 3% Hybrid, and 45% Remote job distribution.
Case Review Representative

Case Review Representative

OncoHealth

Guaynabo, PR • On-site, Remote

$13 - $15/hr

Full-time

Posted 18 days ago

Job description

About OncoHealth
OncoHealth is a leading digital health company dedicated to helping health plans, employers, providers, and patients navigate the physical, mental, and financial complexities of cancer through technology enabled services. Supporting more than 14 million people in the US and Puerto Rico, OncoHealth offers digital solutions for treatment review and virtual care across all cancer types.
About the Role
The Case Review Representative serves as a one-stop shop and intake of all calls (members and providers). Resolves tier one issues (user resets, provider data management, fax and letter receipt, general questions).
Primary Responsibilities
  • Flexible to work rotational shifts inside our office hours from 8:00 a.m. – 8:00 p.m. EST to cover the operational needs of the company. Shifts can range anywhere between Monday – Friday 8:00 am to 8:00 pm EST and Saturdays 8:30 am - 5:00 pm EST (Office hours may change/extend upon operational needs)
  • Fax intake and labeling
  • Prior authorization creation
  • Quality Performance Program Outreach when assigned
  • Triage and manage inbound calls, routing case specific calls to an appropriate team member, and resolving tier 1 level issues
  • Triage and manage inbound emails from health plan clients, routing case specific emails to an appropriate team member, and resolving tier 1 level issues
  • Triage request/claims processing issues to health plans as needed Prior authorization creation
  • Quality Performance Program Outreach when assigned
About You
  • College degree or relevant experience preferred
  • Fully Bilingual (English and Spanish)
  • Remote/hybrid work experience preferred
  • A minimum of 2 years of healthcare related administrative experience and/or customer service or relevant educational attainment required
  • Skills for implementation of systems for program effectiveness and productivity required
  • Systems/Tools: MS Office Suite proficient
About the Location
OncoHealth is committed to remote, hybrid or in office work options. Our Team in Puerto Rico reports to the office at least 2 times per month (advance notice provided/mandatory requirement) and can work remotely from home the rest of the days. Employees are welcome to work from the office every day if wanted.

Our Culture

Taking ownership of quick action, critically thinking through the needs, and working well with others are key competencies of team member success. Our leadership is dedicated to building a culture based on respect, clinical excellence, innovation – all with a focused mission of putting patients first!

We offer a full benefit package on your first day, along with a company bonus. You may visit or work from our very modern and engaging offices, and experience a fun, collaborative environment where social activities and community events matter. We enjoy being together!
OncoHealth is committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and team members without regard to race, color, religion, marital status, age, national origin, ancestry, physical or mental disability, medical condition, pregnancy, genetic information, gender, sexual orientation, gender identity or expression, veteran status, or any other status protected under federal, state, or local law. All employment decisions are based on qualifications, merit, and business need.

The Opportunity

The cost of cancer related medical services and prescription drugs in the United States is expected to reach $246 billion by 2030. OncoHealth has enjoyed rapid growth over the past 3 years and seeks smart, collaborative people to join its team. We have just under 250 team members, so we can move swiftly but precisely to the market needs of our customers. Strongly backed financially by Arsenal Capital Partners amp; McKesson Corporation, we remain in an investment and growth mode. This means we are open-minded to how we get the work done – now is the perfect time to talk to us!

Our Current Solutions

Through the use of OncoHealth's utilization management system, OneUM, our customers can use a single e-Prior Authorization portal for all oncology drug request and treatments. Our system improves quality of care, reduces provider abrasion and gives health plans visibility into the total cost of oncology treatment.

OncoHealth offers Oncology Insights Pro, an analytic software solution that enables health plans to use data and analytics to improve oncology programs. Using real world data, our engineers normalize data to create analytic dashboards with drill down compatibilities. The data is the paired with expert guidance providing the strategies an insight needed to keep up with the continuing evolving cancer treatment landscape.

OncoHealth offers Pharmacy Consulting services to health plans and pharmaceutical companies. New cancer treatments are entering the market at an unrelenting pace. Since 2018, the FDA approved 121 new cancer applications including 49 novel cancer drug entities. Our Board-Certified Oncology Pharmacologists can help health plans update drug policies, offer utilization management and formulary advice, and development training for staff.

OncoHealth's latest offering is Iris, a digital telehealth platform that delivers personalized, oncology-specific support to navigate the physical symptoms and emotional challenges caused by cancer and cancer treatment. Powered by technology, staffed 24X7, and delivered with empathy, Iris allows patients to connect with trained oncology experts and receive personalized, oncology-specific telehealth support.

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