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Remote Utilization Review Nurse Jobs (NOW HIRING)

Personify Health

Utilization Review Nurse - RN

$30 - $38/hr

Current, unrestricted RN license in the United States or a U.S. territory (compact license accepted ... Utilization review/utilization management experience preferred Technical Skills: * Proficiency with ...

iMPROve Health

Contingent UR/LTSS Registered Nurse

... Utilization Review / Long-Term Services & Supports (UR/LTSS) Review Nurse . This fully remote ... position supports Michigan Medicaid programs by conducting Nursing Facility Level of Care (LOC ...

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

As of Aug 16, 2026, the average hourly pay for remote utilization review nurse in the United States is $42.28, according to ZipRecruiter salary data. Most workers in this role earn between $33.41 and $48.56 per hour, depending on experience, location, and employer.

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.

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.

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Remote Utilization Review Nurse jobs near you
Infographic showing various Remote Utilization Review Nurse job openings in the United States as of August 2026, with employment types broken down into 1% As Needed, 83% Full Time, 13% Part Time, and 3% Contract. Highlights an 90% Physical, 3% Hybrid, and 7% Remote job distribution, with an average salary of $87,946 per year, or $42.3 per hour.

Utilization Review Nurse - RN

Personify Health

Remote

$30 - $38/hr

Full-time

Medical, Dental, Retirement, PTO

Posted 20 days ago

Job description

Overview
Who We Are
Because health is personal. That's why Personify Health created the first and only personalized health platform-bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. We serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes. Together, our team is on a mission to empower people to lead healthier lives.
Learn even more about the work that drives us at personifyhealth.com.
Responsibilities
Ready to turn clinical expertise into life-changing decisions, one review at a time?
Why This Role Matters
Every determination you make decides whether a member gets the care they need, when they need it. This role sits at the exact point where clinical judgment meets real-world impact, translating evidence-based criteria into decisions that protect members and keep the organization compliant, efficient, and trusted. Get it right, and members move forward with the right care in the right setting, network partners stay strong, and the organization avoids costly, avoidable risk. Get it wrong, or get it slow, and everyone feels it, from the member waiting on an answer to the Medical Director who depends on a clean, well-documented case. Your reviews are the front line of quality, and your accuracy is what turns a good UM program into a great one.
Schedule: Monday-Friday, 8:00 AM-5:00 PM Pacific Time, with rotating Saturday coverage as required.
What You'll Actually Do
  • Conduct medical-necessity reviews: Evaluate requested services against benefit language, medical policy, and nationally recognized criteria (MCG, NCCN) to determine the appropriate level of care, applying state and federal requirements at every step.
  • Escalate non-certifications with precision: Route cases that don't meet criteria to the Medical Director for secondary clinical review, ensuring every adverse determination is timely, defensible, and aligned with NCQA/URAC accreditation standards.
  • Dig into the clinical record: Analyze documentation for completeness, flag acuity and risk indicators, catch inconsistencies or gaps, and act fast with outreach or escalation when something doesn't add up.
  • Prioritize with purpose: Manage a caseload by urgency, regulatory deadline, and member impact, and flag barriers early so determinations stay timely and compliant.
  • Redirect care in-network: Confirm eligibility, benefits, authorization, and network status to steer members toward in-network, benefit-compliant options when clinically appropriate.
  • Build the appeals case: Prepare clinical summaries and documentation, coordinate peer-to-peer discussions with physicians, and route appeals (including IRO referrals) accurately and on time.
  • Document with rigor: Capture every review, rationale, criteria citation, and outcome in UM systems in real time, creating a clean audit trail that supports quality oversight and reporting.
  • Hit the bar, every time: Meet productivity, quality, accuracy, and turnaround standards, participate in calibration activities, and put feedback into action immediately.
  • Protect what matters: Maintain HIPAA compliance and confidentiality using minimum-necessary standards, and stay current on required training and annual competencies.
  • Show up for the team: Cross-train and flex into coverage roles as needed, keeping operations running and service commitments met.

Qualifications
What You Bring to Our Team
Education & Experience:
  • Current, unrestricted RN license in the United States or a U.S. territory (compact license accepted where applicable)
  • Graduate of an accredited nursing program (ADN or diploma required; BSN preferred)
  • 1-2+ years of recent clinical experience (acute care, med-surg, ICU/ED, or similar setting)
  • Utilization review/utilization management experience preferred

Technical Skills:
  • Proficiency with Microsoft Word, Excel, and Outlook
  • Working knowledge of ICD-10, CPT, and HCPCS coding and medical claims
  • Ability to interpret medical records and apply evidence-based criteria and plan medical policies
  • Comfort working across multiple screens and systems with strong typing proficiency
  • Ability to work independently within UM platforms and workflows after training

Benefits
The Highlights:
  • Competitive base salary and benefits effective day one
  • Comprehensive medical and dental through our own health solutions (yes, we use what we build)
  • Paid Time Off-rest and recharge time is non-negotiable
  • Mental health support, retirement planning, and financial protection
  • Professional development with clear career progression and learning budgets
  • Mission-driven culture where diverse perspectives drive real impact on people's health

Want the full picture? Visit personifyhealthbenefits.com to explore our complete benefits package, wellness programs, and other employee perks.
Compensation: This position offers a base salary range of $30.00-$38.00 per hour, depending on location, skills, and experience. You're eligible for our full benefits package starting day one.
Our Commitment: Personify Health is an equal opportunity employer committed to diversity, equity, inclusion, and belonging. We cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive-because diversity is core to who we are and critical to our work in health and wellbeing.
Stay Safe: Personify Health will never ask for payment or sensitive personal information like social security numbers during hiring. All official communication comes from verified company email addresses and or our secure applicant tracking system. Suspicious requests? Report them to talent@personifyhealth.com. View all legitimate openings at personifyhealth.com/careers.

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