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Remote Utilization Review Rn Jobs in Pennsylvania

The CKHobbie Group

This is a remote position. Seeking a detail-oriented and highly analytical Registered Nurse (RN) to ... In this role, you will be responsible for reviewing and abstracting clinical data from medical ...

Novacore

Medical Review Nurse

Conshohocken, PA · Remote

The Medical Review Nurse is a registered nurse who can assist Novacore's Claim and Underwriting ... Ability to work independently in a remote setting. * Ability to work with multiple offices and ...

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

As of Jul 21, 2026, the average hourly pay for remote utilization review rn in Pennsylvania is $42.38, according to ZipRecruiter salary data. Most workers in this role earn between $33.51 and $48.65 per hour, depending on experience, location, and employer.

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

To excel as a Remote Utilization Review RN, you need a valid RN license, strong clinical judgment, and knowledge of utilization management principles. Familiarity with electronic medical records (EMR), utilization management software, and guidelines such as InterQual or MCG is typically required. Outstanding attention to detail, critical thinking, and effective communication skills help you collaborate with healthcare teams and advocate for appropriate patient care. These competencies are crucial for ensuring medical necessity, regulatory compliance, and optimal resource use in a remote setting.

What is a Remote Utilization Review RN?

A Remote Utilization Review RN is a registered nurse who evaluates the necessity, appropriateness, and efficiency of healthcare services provided to patients, typically working from a remote location. They review medical records, apply clinical guidelines, and collaborate with healthcare providers to ensure patients receive the right care at the right time. Their work helps manage healthcare costs and improves patient outcomes by preventing unnecessary treatments or hospital stays. Remote Utilization Review RNs often work for insurance companies, hospitals, or healthcare organizations, and use secure digital platforms to conduct their reviews.

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

AspectRemote Utilization Review RnRemote Case Manager Rn
CertificationsRN license, Utilization Review certification (e.g., URAC)RN license, Case Management certification (e.g., CCM)
Work EnvironmentReviewing medical records, insurance policies, telehealth platformsCoordinating patient care, discharge planning, telehealth
Employer & IndustryInsurance companies, healthcare organizationsHospitals, insurance providers, healthcare agencies

Remote Utilization Review Rns primarily focus on evaluating medical necessity for insurance coverage, while Remote Case Manager Rns coordinate patient care and discharge planning. Both roles require RN licensure and involve telehealth work, but they serve different functions within healthcare and insurance industries.

What are some common challenges Remote Utilization Review RNs face when working from home, and how can they be addressed?

Remote Utilization Review RNs often encounter challenges such as maintaining clear communication with interdisciplinary teams, managing time efficiently, and staying updated on changing payer guidelines. To address these challenges, it's important to establish consistent check-ins with team members via video or chat platforms, use digital tools to organize and prioritize caseloads, and participate in ongoing training sessions provided by employers. Adhering to a structured daily routine and leveraging available technology can help ensure productivity and high-quality reviews while working remotely.
What are popular job titles related to Remote Utilization Review Rn jobs in Pennsylvania? For Remote Utilization Review Rn jobs in Pennsylvania, the most frequently searched job titles are:
What job categories do people searching Remote Utilization Review Rn jobs in Pennsylvania look for? The top searched job categories for Remote Utilization Review Rn jobs in Pennsylvania are:
What cities in Pennsylvania are hiring for Remote Utilization Review Rn jobs? Cities in Pennsylvania with the most Remote Utilization Review Rn job openings:
Remote Utilization Review Rn jobs near you
Infographic showing various Remote Utilization Review Rn job openings in Pennsylvania as of July 2026, with employment types broken down into 81% Full Time, 13% Part Time, 1% Temporary, 4% Contract, and 1% Nights. Highlights an 39% Physical, 6% Hybrid, and 55% Remote job distribution, with an average salary of $88,158 per year, or $42.4 per hour.
Clinical Appeals Nurse - Full Time Remote - Jefferson Health

Clinical Appeals Nurse - Full Time Remote - Jefferson Health

Thomas Jefferson University Hospitals, Inc.

Philadelphia, PA • On-site, Remote

Full-time

Medical, Dental, Vision, Life, Retirement

Posted 12 days ago

Jefferson Health rating

7.7

Company rating: 7.7 out of 10

Based on 346 frontline employees who took The Breakroom Quiz

158th of 886 rated healthcare providers

Job description

Job Details
Reviews payor denials and audits for potential lost revenue. Writes comprehensive, factual arguments to present to third-party payers, medical review boards, or other responsible parties applying clinical criteria to establish medical necessity. Functions as a hospital liaison with external third-party payors to appeal denied claims. Works closely with Physician advisor team to facilitate appeals to payors. Monitors and reports payor trends to management team.
Job Description
Clinical Appeals Nurse - Full Time Remote - Jefferson Health
Articulates the job's main responsibilities. This is not intended to be an exhaustive list of all essential functions or all duties performed. The essential functions listed below and percentage of time may vary between departments and locations, and are subject to change based on management discretion and organizational needs. Other responsibilities may be assigned at the discretion of management to meet organizational needs.
  • Creates an appeal letter to uphold the procedure based on medical policy guidelines of the payor and the documentation found in the hospital/physician information system.
  • Facilitates write off accounts that cannot provide adequate medical necessity or documentation for the payor to meet their guidelines.
  • Investigates and coordinates completion of patient records required to retrospectively precertify accounts and appeal insurance denials.
  • Contacts insurance companies and conducts appeals via telephone or email.
  • Coordinates appeals that need a physician's input for the payor and writes off claims that have no further appeal rights.
  • Identifies areas for revenue loss due to documentation or processes not being reimbursable thru payors.
  • Ensures that all appeals are sent to the correct payor within the appeal guidelines.
  • Ensures compliance with regulatory and accrediting requirements.
  • Reviews claim documentation and pulls supporting medical documentation from the system to support the medical policy guidelines of the payor.
  • Searches for supporting clinical evidence to support appeal arguments when existing resources are unavailable.

Qualifications:
The requirements listed below are representative of the knowledge, skill, and/or ability required or preferred.
Education - Required
  • Bachelor's Degree Nursing or
  • Specialized Diploma

Experience - Required
  • 10 years of clinical or case management/utilization review experience

Knowledge, Skills and Abilities - Required
  • Ability to read medical charts and identify deficiencies in documentation content.
  • Ability to adapt to ongoing changes within the health insurance industry in order to effectively implement positive changes.
  • Knowledge of Interqual/medical policy criteria, case management principles, utilization review, and hospital departmental procedures.
  • Knowledge of coding for payment of claims.
  • Insurance knowledge of payors and their unique rules.
  • Epic workflow experience with notes in account history and WQ workflows.
  • Intermediate Excel and MS Word experience.
  • Must complete RCE Training and pass test with 80% or better.

Licenses and Certifications - Required
  • RN - Licensed Registered Nurse_PA - State of Pennsylvania

Work Shift
Workday Day (United States of America)
Worker Sub Type
Regular
Employee Entity
Thomas Jefferson University
Primary Location Address
1101 Market, Philadelphia, Pennsylvania, United States of America
Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.
Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status.
Benefits
Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.
For more benefits information, please click here

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About Jefferson Health

Sourced by ZipRecruiter

Jefferson Health is a revered name in the healthcare sector, based in Philadelphia, Pennsylvania, US. This nonprofit health system is dedicated to delivering high-quality, compassionate clinical care and services across the region. The organization was founded in 1824 as Jefferson Medical College, and over the years, it has grown into a vast network of physicians and specialists, hospitals, outpatient and urgent care facilities. Offering a comprehensive range of healthcare services, Jefferson Health covers areas including cancer care, neuroscience, orthopedics, and cardiovascular care, among others. The organization's mission is to improve lives by promoting overall health and wellness, emphasizing value-based care, and making innovative medical advancements. Besides, one of their notable achievements includes being recognized by the National Academy of Medicine as a national leader in patient safety improvements.

Industry

Hospitals and health care and social assistance

Company size

10,000+ Employees

Headquarters location

Philadelphia, PA, US

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