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Remote Utilization Review Rn Jobs in Gainesville, GA

Molina Healthcare

Registered Nurse

Alpharetta, GA · Remote

$29.05 - $67.97/hr

... utilization review (prospective, retrospective and concurrent clinical review), medical claims ... Nurse (RN). License must be active and unrestricted in state of practice. Compact license is ...

Molina Healthcare

Registered Nurse

Lawrenceville, GA · Remote

$29.05 - $67.97/hr

... utilization review (prospective, retrospective and concurrent clinical review), medical claims ... Nurse (RN). License must be active and unrestricted in state of practice. Compact license is ...

Molina Healthcare

Registered Nurse

Athens, GA · Remote

$29.05 - $67.97/hr

... utilization review (prospective, retrospective and concurrent clinical review), medical claims ... Nurse (RN). License must be active and unrestricted in state of practice. Compact license is ...

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

As of Jun 1, 2026, the average hourly pay for remote utilization review rn in Gainesville, GA is $39.43, according to ZipRecruiter salary data. Most workers in this role earn between $31.15 and $45.29 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 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 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 popular job titles related to Remote Utilization Review Rn jobs in Gainesville, GA? For Remote Utilization Review Rn jobs in Gainesville, GA, the most frequently searched job titles are:
What job categories do people searching Remote Utilization Review Rn jobs in Gainesville, GA look for? The top searched job categories for Remote Utilization Review Rn jobs in Gainesville, GA are:
What cities near Gainesville, GA are hiring for Remote Utilization Review Rn jobs? Cities near Gainesville, GA with the most Remote Utilization Review Rn job openings:
Remote Utilization Review Rn jobs near you
Utilization Management Director - RN Required - Remote

Utilization Management Director - RN Required - Remote

Northeast Georgia Health System

Gainesville, GA • On-site, Remote

Full-time

Posted 21 days ago

Northeast Georgia Health System rating

7.5

Company rating: 7.5 out of 10

Based on 140 frontline employees who took The Breakroom Quiz

183rd of 864 rated healthcare providers

Job description

Job Category:
Executive Leadership, Revenue Cycle
Work Shift/Schedule:
8 Hr Morning - Afternoon
Northeast Georgia Health System is rooted in a foundation of improving the health of our communities.
About the Role:
Job Summary
The Director of Utilization Management (UM) is responsible for leading and managing the Utilization Management (UM) functions at Northeast Georgia Medical Center. This position plays a critical role in ensuring correct status assignment, optimizing reimbursement, minimizing denials, improving case mix index (CMI), and ensuring appropriate utilization of hospital resources. The Director works collaboratively with hospital leadership, physicians, case management, finance, and compliance teams to enhance quality reporting, patient outcomes, and financial integrity. This role serves as a key liaison between clinical and financial operations, ensuring a seamless integration of documentation integrity with utilization management to drive efficiency, compliance, and revenue cycle optimization.
Minimum Job Qualifications
  • Licensure or other certifications: Registered Nurse, UR specific certification preferred (CCM, ACM, CPUR)
  • Educational Requirements: Bachelors Degree
  • Minimum Experience: Minimum of 7 years UR with progressive Revenue Cycle leadership experience of 2 or more years.
  • Other:

Preferred Job Qualifications
  • Preferred Licensure or other certifications:
  • Preferred Educational Requirements: Master's Degree in Nursing or other health related field preferred
  • Preferred Experience:
  • Other:

Job Specific and Unique Knowledge, Skills and Abilities
  • Proven ability to lead teams, manage budgets, and implement strategic initiatives.
  • Strong ability to educate and influence physicians, staff, and leadership on UM best practices.
  • Experience in data analysis, KPI tracking, and performance improvement strategies.
  • Expertise in medical necessity criteria, payer regulations, and revenue cycle principles.
Essential Tasks and Responsibilities
  • Oversee day-to-day operations of the Utilization Management Department, ensuring compliance with payer requirements and regulatory standards.
  • Work closely with case management, managed care, and patient financial services to streamline utilization review and enhance hospital financial performance.
  • Monitor and analyze key performance indicators (KPIs), financial goals, and length of stay (LOS) metrics to drive performance improvements.
  • Recruit, train, and manage a high-performing UM team, ensuring operational alignment with hospital objectives.
  • Manage departmental budgets, ensuring financial responsibility and resource allocation
  • Develop and implement performance metrics to evaluate team effectiveness and drive continuous improvement.
  • Foster strong relationships with internal and external stakeholders, including hospital executives, physicians, and payers.
  • Provide data-driven insights and strategic recommendations to hospital leadership regarding UM performance.
  • Act as the operational leader for process improvement initiatives related to utilization management, and revenue cycle optimization.
  • Work closely with Physician Advisors to develop and revise policies and procedures related to clinical status determination, medical necessity, denials and appeals, and physician education.
  • Review daily, weekly and monthly reports to monitor and analyze performance of UM departments, assess data against KPI standards and goals, and identifies trends to make adjustments as indicated. Keeps leadership, staff, and clinical staff (where appropriate) informed.
  • Oversees UM working closely with Case Management and other members of the interdisciplinary team to ensure effective collaboration for length of stay and throughput.
  • Communicate with and educate physicians and other key stake holders regarding Utilization Review policies, practices, and procedures to ensure safe, effective services, along with appropriate transitions of care.
  • Assesses departmental workload to determine appropriate staff allocations to ensure productivity standards are being met consistently.
  • Works closely with physicians and staff to provide and monitor clinical/financial data for the purpose of improving hospital/physician performance and anticipating payer and managed care demands.
  • Actively participates as the operational leader for UM in committees including but not limited to MRUR; Compliance; Policy and Procedures; and Quality
  • Identifies and maintains good relationships with other departments such as Managed Care, Patient Financial Services, Patient Access, and others so to facilitate the utilization review processes and to provide continuity of care.
Physical Demands
  • Weight Lifted: Up to 20 lbs, Frequently 31-65% of time
  • Weight Carried: Up to 20 lbs, Frequently 31-65% of time
  • Vision: Moderate, Frequently 31-65% of time
  • Kneeling/Stooping/Bending: Occasionally 0-30%
  • Standing/Walking: Constantly 66-100%
  • Pushing/Pulling: Constantly 66-100%
  • Intensity of Work: Occasionally 0-30%
  • Job Requires: Reading, Writing, Reasoning, Talking, Keyboarding, Driving

Working at NGHS means being part of something special: a team invested in you as a person, an employee, and in helping you reach your goals.
NGHS: Opportunities start here.
Northeast Georgia Health System is an Equal Opportunity Employer and will not tolerate discrimination in employment on the basis of race, color, age, sex, sexual orientation, gender identity or expression, religion, disability, ethnicity, national origin, marital status, protected veteran status, genetic information, or any other legally protected classification or status.

What Northeast Georgia Health System employees say

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About Northeast Georgia Health System

Sourced by ZipRecruiter

Northeast Georgia Health System (NGHS) is a not-for-profit community health system dedicated to improving the health and quality of life of the people of Northeast Georgia. Through the services of a medical staff of more than 800 physicians, the residents of Northeast Georgia enjoy access to the state’s finest and most comprehensive medical services. It is our mission to improve the health of our community in all we do.

Industry

Health care and social assistance

Company size

5,001 - 10,000 Employees

Headquarters location

Gainesville, GA, US

Year founded

1951

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