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Remote Utilization Review Rn Jobs in Lexington, SC

Bcbsa

Director, Trade Client Relations

Columbia, SC · Remote

$155K - $175K/yr

Analytics Team - Collaborate on drug trends and utilization data to inform clinical policy ... Clinical Team - Liaise with Clinical team to review clinical data and policy requirements as needed

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Remote Utilization Review Rn information

See Lexington, SC salary details

$18

$36

$59

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

As of Aug 6, 2026, the average hourly pay for remote utilization review rn in Lexington, SC is $36.19, according to ZipRecruiter salary data. Most workers in this role earn between $28.61 and $41.59 per hour, depending on experience, location, and employer.

What are the key skills and qualifications needed to thrive as a remote utilization review RN?

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 Lexington, SC? For Remote Utilization Review Rn jobs in Lexington, SC, the most frequently searched job titles are:
What job categories do people searching Remote Utilization Review Rn jobs in Lexington, SC look for? The top searched job categories for Remote Utilization Review Rn jobs in Lexington, SC are:
What cities near Lexington, SC are hiring for Remote Utilization Review Rn jobs? Cities near Lexington, SC 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 Lexington, SC as of August 2026, with employment types broken down into 1% As Needed, 80% Full Time, 17% Part Time, and 2% Contract. Highlights an 89% Physical, 2% Hybrid, and 9% Remote job distribution, with an average salary of $75,278 per year, or $36.2 per hour.

Clinical Analyst & Coding Specialist - Contract - Columbia, SC

SUNSHINE ENTERPRISE USA LLC

Columbia, SC • Remote

Contractor

Posted 15 days ago

Job description

Clinical Analyst & Coding Specialist Location: Columbia, SC Hybrid (80% remote, onsite for required trainings and meetings). Interview Process: 1 round, Virtual/Online Duration: 12 Months Employment Type: Contract Experience Required: 10+ Years Candidate location: Candidate MUST be a SC resident. No relocation allowed.

Project Scope: Seeking an experienced Business Analyst (Clinical Analyst & Coding Specialist) to support ongoing Medicaid operations and healthcare system initiatives. The consultant will serve as a Subject Matter Expert (SME) for medical coding, Medicaid policy, and business analysis while collaborating with business and technical teams to support coding updates, policy implementation, and business process improvements. Key Responsibilities: Coordinate annual and quarterly ICD-10, CPT, and HCPCS code updates.

Review and analyze coding changes to determine business and operational impacts. Prepare code change documentation for stakeholder review. Collaborate with business users, stakeholders, and technical teams to implement coding and policy updates.

Participate in meetings related to healthcare systems modernization initiatives. Serve as a Subject Matter Expert (SME) for medical coding methodologies and Medicaid-related processes. Research business rules, requirements, and workflows to develop recommendations.

Maintain business rules, process documentation, and requirements repositories. Support process documentation, knowledge transfer, and training activities. Review medical records against established criteria to determine medical necessity when required.

Assist with additional healthcare and project-related initiatives. Required Skills & Experience: 10+ years of experience in healthcare insurance, medical review, program integrity, or appeals. 5+ years working with IT developers/programmers in a payer environment.

5+ years of medical coding experience in a payer environment. 3+ years of clinical experience in a healthcare environment. Strong knowledge of ICD-10, CPT, and HCPCS coding methodologies.

Strong knowledge of anatomy, physiology, pharmacology, and medical terminology. Experience gathering business requirements and documenting business processes. Excellent analytical, communication, and stakeholder management skills.

Preferred Skills: Experience with healthcare policy remediation. Claims processing systems experience. Microsoft Office Suite proficiency.

Experience with Optum Encoder or other medical coding software. Medicaid and healthcare payer systems experience. Experience supporting healthcare system modernization initiatives.

Education Bachelor of Science in Nursing (BSN) or Associate Degree in Nursing (ADN). Certification: Active, unrestricted Registered Nurse (RN) license. Current CPC (Certified Professional Coder) or CCS (Certified Coding Specialist) certification.

ICD-10 proficiency certification or ability to obtain certification within one year.

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