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Remote Utilization Review Nurse Jobs in Fountain Inn, SC

LifeSource, Inc.

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Primary Care MD/DO - Medical Director & Geriatric Assessments

Greenville, SC · Remote

Collaboration of Primary Care NP/PA's * * This can be 100% remote * Control your Schedule ... Case Review and support from a group of clinical peers * Excellent compensation packages * Health ...

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Remote Utilization Review Nurse information

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$19

$37

$61

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

As of Aug 28, 2026, the average hourly pay for remote utilization review nurse in Fountain Inn, SC is $37.74, according to ZipRecruiter salary data. Most workers in this role earn between $29.81 and $43.37 per hour, depending on experience, location, and employer.

What is a remote utilization review nurse?

A Remote Utilization Review Nurse is a registered nurse who evaluates the necessity, appropriateness, and efficiency of healthcare services and treatments, typically from a remote location such as their home. They review patient medical records, apply clinical guidelines, and collaborate with providers and insurance companies to ensure patients receive appropriate care while managing healthcare costs. This role often involves making coverage determinations, conducting pre-authorizations, and participating in appeals processes. Remote Utilization Review Nurses play a critical role in improving patient outcomes and resource allocation within the healthcare system.

What does a remote utilization review nurse do?

As a remote utilization nurse, your duties are to work from home or a remote location to review patient medical records and prepare a range of paperwork for different types of actions a hospital or health care provider can take. Your responsibilities are to determine patient coverage, carry out denial of service authorizations, and negotiate different treatment options and hospital stay length for patients. You rely on your knowledge of treatment options and diseases to determine the level of appropriate care for a patient. Because you telecommute, you also need good technical skills.

What are the key skills and qualifications needed to thrive as a remote utilization review nurse?

To thrive as a Remote Utilization Review Nurse, you need a current RN license, clinical experience, and a solid understanding of medical necessity criteria and healthcare regulations. Familiarity with utilization management software, EHR systems, and certifications like CCM or URAC are highly valued. Strong analytical thinking, attention to detail, and effective communication skills enable success in evaluating clinical documentation and collaborating with providers remotely. These skills and qualifications are essential to ensure efficient, compliant care decisions that optimize patient outcomes and resource use.

How does a remote utilization review nurse collaborate with physicians and other healthcare team members while working remotely?

As a Remote Utilization Review Nurse, collaboration with physicians, case managers, and other healthcare professionals is primarily conducted through secure digital platforms such as email, video conferencing, and electronic health record systems. Effective communication is essential to discuss patient care plans, clarify medical necessity, and ensure compliance with utilization policies. Nurses in this role often participate in virtual meetings or case conferences to present findings and recommendations. Building strong working relationships remotely requires proactive communication, responsiveness, and familiarity with digital collaboration tools.

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

AspectRemote Utilization Review NurseRemote Case Manager
CertificationsRN license, possibly CCM or UR certificationsRN license, CCM or case management certifications
Work EnvironmentHealthcare facilities, insurance companies, telehealthInsurance companies, healthcare organizations, telehealth
Job FocusReview medical necessity, approve or deny servicesCoordinate patient care, arrange services, discharge planning

Remote Utilization Review Nurses primarily evaluate medical necessity for services, while Remote Case Managers coordinate patient care and discharge planning. Both roles require nursing credentials and work in healthcare or insurance settings, but their core responsibilities differ. Understanding these distinctions helps job seekers find the best fit for their skills and career goals.

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Remote Utilization Review Nurse jobs near you
Infographic showing various Remote Utilization Review Nurse job openings in Fountain Inn, SC as of August 2026, with employment types broken down into 1% As Needed, 85% Full Time, 11% Part Time, 2% Contract, and 1% Nights. Highlights an 87% Physical, 3% Hybrid, and 10% Remote job distribution, with an average salary of $78,500 per year, or $37.7 per hour.

Medical Management Coordinator (Remote)

Spartanburg Regional Healthcare System

Spartanburg, SC • Remote

Full-time

Posted 3 days ago

New

Spartanburg Regional Healthcare System rating

6.7

Company rating: 6.7 out of 10

Based on 117 frontline employees who took The Breakroom Quiz

532nd of 895 rated healthcare providers

Job description

Job Requirements

Position Summary

The Medical Management Coordinator coordinates all utilization management, and case management activities for the Spartanburg Regional Healthcare System group. The position provides support function to the RHP Medical Management Committee. Must meet productivity standards, complete work in a timely manner. Must be flexible and adapt to changes in the work environment; manage competing demands; change the approach or method to best fit the situation; be able to cope with delay or unexpected events. Take responsibility; keep commitments; complete tasks on time. Volunteer readily; take independent actions; ask for and offer help when needed.

* Only Applicants from the following states: Alabama, Arizona, Connecticut, Delaware, Florida, Georgia, Indiana, Kansas, Kentucky, Louisiana, Maryland, Michigan, North Carolina, Pennsylvania, Rhode Island, South Carolina, Virginia, West Virginia, Wisconsin.

Minimum Requirements

Education           

  • Registered Nurse

Experience        

  • 5 years clinical experience
  • 3 years Utilization Management or Case Management Experience

License/Registration/Certifications       

  • Valid Driver’s license with good driving record

 

Core Job Responsibilities

  • Responsible for the delegated Utilization Review activities for SRHS Health Plan, and others as needed.
  • Coordinates outpatient service review, precertification review, and certification review activities.
  • Review all incoming clinical for outpatient service precertification using specified criteria.
  • Facilitate discussions with RHP Medical Director of cases that require clinical review related to active cases, extended length of stay, catastrophic cases, difficult discharge dispositions, and appropriate levels of care. Refer any cases to external specialist for review when needed.
  • Performs subsequent reviews based on criteria guidelines.
  • Communicates daily with outside facilities/providers results of requested review. Displays appropriate communicates avenues with facilities, case managers and DCP’s.
  • Maintains documents and service in a manner that achieves and maintains member confidentiality and is consistent with HIPAA guidelines.
  • Maintain and update data bases logging Medical Director Reviews, Appeal and statistics in compliance with URAC standards.
  • Research and review any claims issues related to utilization management and / or medical necessity from Third Party Administrator. Communicate results of review to Third Party Administrator.
  • Maintain and update data bases logging Medical Director Reviews, Appeal and statistics in compliance with URAC standards.
  • Professionally manages member/customer requests and complaints. Seeks to resolve customer complaints and problems. Provides information regarding the appeal process to members as requested, and serves as a resource to members, providers, and RHP.
  • Provide notification to Stop Loss carrier and Third-Party Administrator of any plan participant with potential high dollar claims based on medical reviews.
  • Provide clinical updates as requested
  • Work w/ Plan Administrators on unique cases that may require special considerations/exceptions to provide a sound quality and fiscal outcome.
  • Meets with appropriate physicians and other providers  to gain physician understanding and support for the CarePlus Medical Management Utilization Management Process.
  • Negotiates rate with any out-of-network services as needed.
  • Identify potential care management cases through readmissions, emergency room utilization, catastrophic diseases, high dollar treatments, and/or referrals from other CarePlus team members.
  • Determine any appropriate referrals to other CarePlus team members, not limited to, Transitional Care Program, Disease Management Program, Health Coach, or Community Programs.
  • All documents and data are timely, complete, and accurate.
  • Performs all duties within a timely manner.
  • All other duties as assigned.

What Spartanburg Regional Healthcare System employees say

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Hours and flexibility

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About Spartanburg Regional Healthcare System

Sourced by ZipRecruiter

Spartanburg Regional Healthcare System is a leader in the healthcare industry, located in Spartanburg, SC, US. As a comprehensive health system, it offers services encompassing everything from wellness, prevention, and care coordination to specific medical treatments for a wide range of diseases and health issues. Spartanburg Regional Healthcare System was founded in 1921 and has since developed a reputation for excellence and innovative care, growing to include six hospitals, 100 medical offices, 8,000 associates and more than 900 medical staff.

Industry

Recruiting and staffing services

Company size

5,001 - 10,000 Employees

Headquarters location

Spartanburg, SC, US

Year founded

1921

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