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Remote Utilization Review Rn Jobs in Portland, ME

OneAmerica

Clinical Care Consultant

South Portland, ME · On-site +1

... reviews of medical information. This role is responsible for discussing and documenting an ... Current & active Registered Nurse (RN) license in their state of residency required. BSN preferred.

Guardian Recovery

THERAPIST

South Portland, ME · On-site +1

$55K - $86K/yr

Registered Nurse certified as a Psychiatric Nurse, b. Advanced Practice Registered Nurse (APRN) ... C. 10:161A-1.9 employment, with progress towards certification or licensing on file, reviewed by ...

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Remote Utilization Review Rn information

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

As of Jul 11, 2026, the average hourly pay for remote utilization review rn in Portland, ME is $43.26, according to ZipRecruiter salary data. Most workers in this role earn between $34.18 and $49.66 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 Portland, ME? For Remote Utilization Review Rn jobs in Portland, ME, the most frequently searched job titles are:
What job categories do people searching Remote Utilization Review Rn jobs in Portland, ME look for? The top searched job categories for Remote Utilization Review Rn jobs in Portland, ME are:
What cities near Portland, ME are hiring for Remote Utilization Review Rn jobs? Cities near Portland, ME 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 Portland, ME as of July 2026, with employment types broken down into 84% Full Time, 12% Part Time, and 4% Contract. Highlights an 40% Physical, 2% Hybrid, and 58% Remote job distribution, with an average salary of $89,979 per year, or $43.3 per hour.
Remote HEDIS Nurse Reviewer - New England Region

Remote HEDIS Nurse Reviewer - New England Region

Martins Point Health Care

Portland, ME • Remote

$31 - $41/hr

Full-time

Posted 9 days ago

Martin’s Point Health Care rating

7.4

Company rating: 7.4 out of 10

Based on 6 frontline employees who took The Breakroom Quiz

Job description

Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of"people caring for people," Martin's Point employees are on amission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.

Position Summary
 The Nurse HEDIS Reviewer and Auditor is a registered nurse responsible for performing clinical reviews of healthcare data, focusing on HEDIS measures and quality improvement. This position requires strong clinical knowledge and expertise to accurately extract and audit patient data, ensuring it meets HEDIS standards. The Nurse HEDIS Reviewer and Auditor collaborates with cross-functional teams, participates in quality improvement initiatives, and provides clinical insights to enhance healthcare outcomes and compliance with quality benchmarks.
Job Description

Key Outcomes:

  • Performs clinical chart reviews and audits to ensure accuracy and compliance with HEDIS measures.
  • Develops reports to identify HEDIS care gaps and trends and works closely with providers to ensure the necessary services are provided and documented according to HEDIS requirements.
  • Prioritizes reports according to business needs, regulatory requirements, urgency, and other key business factors.
  • Assists in the coordination of outreach efforts to request, collect, and secure clinical documentation from individual providers or provider groups as indicated by individual HEDIS measure specifications.
  • Collaborates with health plan departments to identify HEDIS data sources and develop systems to capture this data in accordance with HEDIS technical specifications, such as supplemental databases.
  • Collaborates with data analysts and quality teams to support performance improvement.
  • Documents findings and recommend strategies to improve HEDIS measure performance.
  • Applies clinical expertise to identify and validate data discrepancies.
  • Educates non-clinical staff on HEDIS requirements and clinical relevance of data.
  • Corresponds with members and clinical providers to effectively coordinate care, obtain medical records and ensure patients receive preventive and chronic disease management services.
  • Develops on-going training and education for both internal and external stakeholders.
  • Completes annual training provided and meet and maintain competency and acceptable performance goals.
  • Other duties and responsibilities, as assigned.

Education/Experience:

  • Bachelor's degree in nursing required
  • 5+ years of experience in the health care industry, in HEDIS and/or quality improvement.
  • Experience in managed care health services environment
  • NCQA and HEDIS Experience.

Required License(s) and/or Certification(s):

  • Active and unrestricted Nursing license.

Skills/Knowledge/Competencies (Behaviors):

  • Demonstrated knowledge of data collection, medical record review, and data extraction.
  • Excellent communication, organization and writing skills.
  • Ability to effectively prioritize work, multi-task, and achieve goals on time; work independently and to self-motivate.
  • Excellent critical thinking skills.
  • Keen attention to detail.
  • Ability to work effectively and collaboratively with internal and external stakeholders.
  • Knowledge of, and skills in, data collection, analysis, and presentation.
  • Excellent oral and written communication skills.
  • Must demonstrate integrity, sound judgement and strong interpersonal skills.
  • Strong knowledge of medical terminology.
  • Strong clinical knowledge and understanding of evidenced-based practice principles and the ability to define appropriate sources for standards of care.
  • Must be able to address quality issues with tact and diplomacy.
  • Proficient use of MS Office with a focus on Excel and report writing software.
  • Proficiency in use of electronic medical records and computer applications.
  • Ability to use data to make decisions.

There are additional competencies linked to individual contributor, provider, and leadership roles. Please consult with your leader to discuss additional competencies that are relevant to your position.

This position is not eligible for immigration sponsorship.

We are an equal opportunity/affirmative action employer.

Martin's Point complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact jobinquiries@martinspoint.org

Do you have a question about careers at Martin's Point Health Care? Contact us at:jobinquiries@martinspoint.org

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