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Remote Utilization Review Nurse Jobs in Rio Rancho, NM

firsthand Health

Remote Triage Nurse

Albuquerque, NM · Remote

The Triage Nurse is a remote Registered Nurse who provides telephone and electronic triage support to firsthand individuals and staff, while also supporting outpatient care coordination. This is ...

DataAnnotation

RN

Rio Rancho, NM · Remote

$40 - $60/hr

MDs, PAs, and Nurses. Benefits ... This a full-time or part-time REMOTE position * You'll be able to choose which projects you want to ...

DataAnnotation

RN

Albuquerque, NM · Remote

$40 - $60/hr

MDs, PAs, and Nurses. Benefits ... This a full-time or part-time REMOTE position * You'll be able to choose which projects you want to ...

Scribe-X

Medical Scribe (Remote)

Albuquerque, NM · Remote

$14 - $17/hr

Anyone looking to begin a career in medicine (MD, DO, PA, NP, or RN) should consider becoming a ... Review completed charts with the provider between patients or at the completion of shift * Update ...

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All JobsRemote Utilization Review Nurse JobsRemote Utilization Review Nurse Jobs in Rio Rancho, NM

Remote Utilization Review Nurse information

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$38

$62

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

As of Jun 10, 2026, the average hourly pay for remote utilization review nurse in Rio Rancho, NM is $38.13, according to ZipRecruiter salary data. Most workers in this role earn between $30.14 and $43.80 per hour, depending on experience, location, and employer.

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

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.

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.

More about Remote Utilization Review Nurse jobs
What are the most commonly searched types of Utilization Review Nurse jobs in Rio Rancho, NM? The most popular types of Utilization Review Nurse jobs in Rio Rancho, NM are:
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What cities near Rio Rancho, NM are hiring for Remote Utilization Review Nurse jobs? Cities near Rio Rancho, NM with the most Remote Utilization Review Nurse job openings:
Remote Utilization Review Nurse jobs near you
Physician Clinical Reviewer-Pediatric Oncologist- REMOTE

Physician Clinical Reviewer-Pediatric Oncologist- REMOTE

Prime Therapeutics LLC

Albuquerque, NM • On-site, Remote

$90.87 - $154.33/hr

Part-time

Posted 29 days ago

Prime Therapeutics rating

7.7

Company rating: 7.7 out of 10

Based on 44 frontline employees who took The Breakroom Quiz

18th of 99 rated pharmacies

Job description

At Prime Therapeutics (Prime), we are a different kind of PBM, with a purpose beyond profits and a unique ability to connect care for those we serve. Looking for a purpose-driven career? Come build the future of pharmacy with us.
Job Posting Title
Physician Clinical Reviewer-Pediatric Oncologist- REMOTEJob Description
Key member of the utilization management team, and provides timely medical review of service requests that do not initially meet the applicable medical necessity guidelines. Routinely interacts with physicians, leadership and management staff, other Physician Clinical Reviewers (PCR), and health plan membersand staff whenever a physician`s input is needed or required.
Responsibilities
Physician Clinical Reviewer - Job Description Responsibilities
  • Reviews cases in which clinical determinations cannot be made by the Initial Clinical Reviewer.
  • Discusses determinations with requesting physicians or ordering providers, when available, within the regulatory time frame of the request by phone or fax.
  • Provides clinical rationale for standard and expedited appeals.
  • Provides assistance and acts as a resource to Initial Clinical Reviewers as needed to discuss cases and problems.
  • Utilizes medical/clinical review guidelines and parameters to assure consistency in the physician review process so as to reflect appropriate utilization and compliance with Prime's policies/procedures, as well as URAC and NCQA guidelines.
  • Ensures documentation of all communications with medical office staff and/or physician/provider is recorded in a timely and accurate manner.
  • Participates in on-going inter-rater reliability training and testing
  • Assists the Medical Director and/or VP, Medical Director in research activities/questions related to the Utilization Management process, interpretation, guidelines, and/or system support.
  • On a requested basis, reviews appeal cases and/or attends hearings for discussion of utilization management decisions.
  • On a requested basis, may function as Medical Director for select health plans or regions, assuming overall accountability for utilization management while working in conjunction with the VP, Medical Director
  • Other duties as assigned.

Education & Experience
  • Education Level
    • DO
    • MBBS
    • MD
  • Required
    • Yes
    • Yes
    • Yes
  • Fields of Study
  • Experience Level
    • 5+ years
  • Required
    • Yes
  • Details
    • Clinical

Must be eligible to work in the United States without the need for work visa or residency sponsorship.
Additional Qualifications
Preferred Qualifications
Physical Demands
  • Must be able to remain in a stationary position 50% of the time. Must be able to "move or traverse"
  • Must be able to constantly operate a computer and/or other office productivity equipment
  • Must be able to hear and constantly communicate information and ideas. Must be able to exchange accurate information
  • Occasionally required to lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds

Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.
Potential pay for this position ranges from $90.87 - $154.33 based on experience and skills.
To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page and click on the "Benefits at a glance" button for more detail (https://www.primetherapeutics.com/benefits).
Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sex (including pregnancy), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law.
We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law.
Prime Therapeutics LLC is a Tobacco-Free Workplace employer.
Positions will be posted for a minimum of five consecutive workdays.

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About Prime Therapeutics

Sourced by ZipRecruiter

Prime Therapeutics, located in Eagan, MN, is a pharmacy benefits management company that has been serving the healthcare industry since its foundation. They are an integral participant in the medical sector, specifically in the realm of health insurance. They focus on providing innovative pharmacy benefits and services to more than 30 million members nationwide. Besides their main pharmacy benefit management, they offer mail service pharmacy, specialty pharmacy, benefits management, and consultative engagement services to ensure individuals have continuous access to affordable prescription drugs. Prime Therapeutics, founded around three decades ago, has grown to stand out as a leader in its industry, thanks to its commitment to improving the health of its clients.

Industry

Insurance services

Company size

1,001 - 5,000 Employees

Headquarters location

Eagan, MN, US

Year founded

1987

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