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Remote Utilization Review Nurse Jobs in Springfield, IL

micro1 AI

Pharmacovigilance Expert

Springfield, IL · Remote

$70 - $80/hr

Remote micro1 is engaging Pharmacovigilance Experts to contribute their advanced drug safety ... Author and review evaluation tasks based on DSURs, PSURs/PBRERs, and associated safety data and ...

micro1 AI

Clinical Pharmacy Technicians

Springfield, IL · Remote

$70 - $80/hr

Remote micro1 is engaging Pharmacovigilance Experts to contribute their advanced drug safety ... Author and review evaluation tasks based on DSURs, PSURs/PBRERs, and associated safety data and ...

All JobsUtilization Review Nurse JobsRemote Utilization Review Nurse JobsRemote Utilization Review Nurse Jobs in Springfield, IL

Remote Utilization Review Nurse information

See Springfield, IL salary details

$19

$39

$63

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

As of Sep 7, 2026, the average hourly pay for remote utilization review nurse in Springfield, IL is $39.13, according to ZipRecruiter salary data. Most workers in this role earn between $30.91 and $44.95 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 Springfield, IL as of August 2026, with employment types broken down into 1% As Needed, 79% Full Time, 15% Part Time, 1% Temporary, and 4% Contract. Highlights an 89% Physical, 3% Hybrid, and 8% Remote job distribution, with an average salary of $81,395 per year, or $39.1 per hour.

Medicaid Business/QA Analyst

MSR Technology Group

Springfield, IL • Remote

Contractor

Re-posted 28 days ago

Job description

Medicaid Business / QA Analyst
  • 7–12+ Month Contract | Remote | No ThirdParty Firms | Medicaid SME Required
  • Candidates with previous State Medicaid program experience will be given strong consideration.
  • Drug screen and background check required as part of onboarding
Position Summary
The Medicaid Business/QA Analyst serves as a subject matter expert (SME) for Medicaid data and processes while performing quality assurance testing within a large-scale Enterprise Data Warehouse (EDW) environment. This position combines program knowledge—eligibility, claims, encounters, provider enrollment, managed care, and reporting—with QA discipline to ensure accuracy, completeness, and usability of EDW deliverables such as data marts, inbound source data loads, outbound extracts, reporting outputs, and operational dashboards.
Key Responsibilities1. Business SME – Medicaid Data & Processes
  • Interpret Medicaid data elements, business rules, and program logic for EDW initiatives.
  • Review inbound data from core systems (eligibility, provider, claims, managed care) for accuracy and mapping alignment.
  • Validate outbound extracts and reporting outputs for accuracy, timeliness, and format requirements.
  • Support development of data marts across eligibility, claims/utilization, provider, managed care, LTSS, and behavioral health.
2. QA Planning & Execution
  • Develop QA plans, scenarios, and test cases aligned to business rules.
  • Perform data reconciliation between source files and EDW target tables.
  • Validate transformations, aggregations, and derived fields.
  • Participate in User Acceptance Testing (UAT) with business stakeholders.
3. Data Quality & Issue Resolution
  • Identify data anomalies, mapping issues, and business rule gaps; work with data engineering and ETL teams to resolve.
  • Ensure referential integrity across eligibility, claims, provider, and plan datasets.
  • Define business data quality rules for ongoing monitoring.
  • Track and document issues in defect management tools.
4. Collaboration & Documentation
  • Work with business stakeholders, vendors, and technical teams to validate requirements and deliverables.
  • Review BRDs, mapping documentation, and data models for accuracy.
  • Maintain QA evidence, testing documentation, and business rule records.
  • Support knowledge transfer related to Medicaid data usage within the EDW.
Required Skills & Qualifications
  • Strong Medicaid business knowledge (eligibility, claims, encounters, provider, managed care).
  • Experience working with EDW environments, including inbound feeds, staging layers, integration layers, data marts, and outbound extracts.
  • Proficiency with SQL for validation and reconciliation.
  • Experience in data warehouse QA/testing, including validating data transformations and dimensional models.
  • Ability to translate Medicaid program rules into testable acceptance criteria.
  • Familiarity with HIPAA compliance and PHI guidelines.
  • Excellent analytical, documentation, and communication skills.
Preferred Qualifications
  • Experience with Medicaid EDW or MMIS modernization projects.
  • Familiarity with provider handbooks, policy documentation, or administrative rules.
  • Experience with managed care data (capitation, encounters, member assignments).
  • Experience validating dashboards or reports in tools such as Tableau, Power BI, or Cognos.
  • Background in data governance or metadata management.