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Remote Utilization Review Rn Jobs in Worcester, MA

VIVA USA INC

Nurse Case Manager

Woonsocket, RI · On-site +1

Through the use of clinical tools and information/data review, conducts comprehensive assessments ... RN with unrestricted active license in Georgia. REQUIRED : Must have experience working a remote ...

VIVA USA INC

Nurse Case Manager

Woonsocket, RI · On-site +1

Through the use of clinical tools and information/data review, conducts comprehensive assessments ... RN with unrestricted active license in Georgia. REQUIRED : Must have experience working a remote ...

Varsity Tutors

NCLEX-RN Tutor

Newton, MA · Remote

$18 - $40/hr

Adapts instruction using UWorld, Kaplan, or ATI practice question banks, content review materials, and test-taking strategy workshops to support BSN and ADN graduates preparing for registered nurse ...

Varsity Tutors

NCLEX-RN Tutor

Waltham, MA · Remote

$18 - $40/hr

Adapts instruction using UWorld, Kaplan, or ATI practice question banks, content review materials, and test-taking strategy workshops to support BSN and ADN graduates preparing for registered nurse ...

Brown & Brown Insurance

Consultant

Southborough, MA · On-site +1

$100K - $125K/yr

This role offers flexibility with remote or hybrid work options. As a Consultant, you will manage ... Analyze data and financial metrics , conduct utilization reviews, and perform peer audits to ...

DaVita

Director, Clinical Services

Southbridge, MA · On-site +1

... review process and provide reports with analysis as requested * Allocate resources according to divisional priorities * Develop a collaborative and unified team REQUIREMENTS: * Active RN License:

Mass Pediatric Aba LLC

Clinical Supervisor/BCBA

Lynn, MA · Remote

$65 - $70/hr

Signing bonus Help Set the Standard for High-Quality ABA Care- Fully Remote Clinical Supervisor ... utilization of scheduled hours with Behavior Technicians ● Develop and monitor individual ...

Varsity Tutors

NCLEX-PN Tutor

Waltham, MA · Remote

$18 - $40/hr

... RN scope questions, pharmacology calculations, and managing anxiety with the adaptive testing format. Adapts instruction using NCLEX-PN specific practice question banks, content review focused on ...

Varsity Tutors

NCLEX-PN Tutor

Newton, MA · Remote

$18 - $40/hr

... RN scope questions, pharmacology calculations, and managing anxiety with the adaptive testing format. Adapts instruction using NCLEX-PN specific practice question banks, content review focused on ...

UnitedHealth Group

Patient Care Coordinator

Worcester, MA · On-site +1

$17.50 - $23/hr

Reviews and facilitates the updating of missing /outdated information in the patient record with ... Ability to work collaboratively with interdisciplinary teams consisting of remote and onsite staff ...

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All JobsUtilization Review Rn JobsRemote Utilization Review Rn JobsRemote Utilization Review Rn Jobs in Worcester, MA

Remote Utilization Review Rn information

See Worcester, MA salary details

$21

$42

$68

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

As of Aug 22, 2026, the average hourly pay for remote utilization review rn in Worcester, MA is $42.13, according to ZipRecruiter salary data. Most workers in this role earn between $33.27 and $48.37 per hour, depending on experience, location, and employer.

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 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 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 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 Worcester, MA?

For Remote Utilization Review Rn jobs in Worcester, MA, the most frequently searched job titles are:

What job categories do people searching Remote Utilization Review Rn jobs in Worcester, MA look for?

The top searched job categories for Remote Utilization Review Rn jobs in Worcester, MA are:

What cities near Worcester, MA are hiring for Remote Utilization Review Rn jobs?

Cities near Worcester, MA 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 Worcester, MA as of August 2026, with employment types broken down into 1% As Needed, 79% Full Time, 15% Part Time, 4% Contract, and 1% Nights. Highlights an 90% Physical, 3% Hybrid, and 7% Remote job distribution, with an average salary of $87,630 per year, or $42.1 per hour.

Remote Pharmacist - Prior Authorization / Coverage Determination

A-Line Staffing Solutions

Woonsocket, RI • Remote

$53/hr

Full-time

Medical, Dental, Vision

This job post has expired 1 day ago. Applications are no longer accepted.

Job description

Remote Pharmacist – Prior Authorization / Coverage Determination

Pay Rate: $53.00/hr

Start Dates

  • September 7
  • September 28

Training Requirements

  • Mandatory paid training is held Monday – Friday, 9:00 AM – 5:30 PM EST for approximately 8–10 weeks.
  • Attendance is mandatory during training. No planned vacation or scheduling conflicts are permitted during this period.
  • Candidates must be available for the entire training schedule before accepting the assignment.
  • Camera must remain on during all virtual training sessions, supervisor meetings, and team meetings.

Schedule

Business Hours:

  • Monday – Friday: 7:00 AM – 8:00 PM EST
  • Saturday & Sunday: 7:00 AM – 4:30 PM EST

Schedule Type: Set Rotation

After training, candidates will be assigned an 8-hour shift based on business needs, which will include either:

  • One weekend day each week, or
  • A rotating weekend schedule.


Job Summary

We are seeking a licensed Registered Pharmacist to support a high-volume, remote Prior Authorization and Coverage Determination team. This role is responsible for reviewing pharmacy benefit requests, interpreting clinical criteria, evaluating Medicare Part D coverage determinations, and ensuring accurate, timely decisions while maintaining compliance with regulatory requirements.

The ideal candidate has experience in Pharmacy Benefit Management (PBM), prior authorizations, managed care, or clinical pharmacy operations and thrives in a productivity-driven remote environment with strict turnaround times.

This is a Safety Sensitive position.

Key Responsibilities

  • Review and evaluate prior authorization and coverage determination requests.
  • Interpret Medicare Part D guidelines, formulary requirements, and clinical criteria.
  • Apply evidence-based clinical judgment using drug information resources and clinical compendia.
  • Ensure compliance with CMS regulations, plan policies, and pharmacy benefit guidelines.
  • Document case reviews accurately and maintain audit-ready records.
  • Manage a high-volume case queue while meeting quality and productivity standards.
  • Perform provider outreach as needed to obtain clinical information or clarify requests.
  • Navigate multiple applications simultaneously while documenting case activity.
  • Work independently in a fast-paced remote environment with minimal supervision.
  • Participate in virtual meetings, coaching sessions, and required training.

Required Qualifications

  • Active Registered Pharmacist (RPh) license in good standing in the state of residence.
  • Experience with:
    • Pharmacy Benefit Management (PBM)
    • Prior Authorizations
    • Coverage Determinations
    • Medicare Part D
    • Formulary management
    • Drug Utilization Review (DUR)
  • Strong understanding of CMS regulations and managed care pharmacy.
  • Excellent documentation and data entry skills.
  • Experience working in high-volume, productivity-driven environments.
  • Strong computer skills, including Microsoft Excel and Word.
  • Ability to navigate multiple computer applications using dual monitors.

Preferred Qualifications

  • Experience with provider outreach and clinical case review.
  • Retail pharmacy combined with managed care or PBM experience.
  • Knowledge of Microsoft Access, PowerPoint, and Visio.
  • Previous remote clinical review experience.

Remote Work Requirements

Candidates must have:

  • A dedicated, quiet workspace free from interruptions.
  • Wired high-speed internet with a minimum of:
    • 25 Mbps download
    • 5 Mbps upload
  • Dual-monitor capability.
  • Ability to remain seated and focused throughout the workday.

Additional Requirements

  • Virtual interviews are conducted through Microsoft Teams.
  • Candidates must be comfortable with extensive data entry, multitasking, and working independently while maintaining productivity standards.
  • Opportunity for full-time employment based on performance.
A-Line Staffing Solutions logo

About A-Line Staffing Solutions

Sourced by ZipRecruiter

A-Line Staffing Solutions is an established full-service recruiting and staffing provider that operates in the industry of human resources and recruitment. Based in Utica, Michigan, A-Line Staffing Solutions has been committed to its mission of providing innovative and effective workforce solutions since its foundation. The company specializes in providing high-quality staffing solutions for a range of disciplines, including Information Technology, Professional, Administrative, Healthcare, and more. A-Line prides itself on its ability to offer comprehensive and tailored staffing solutions in line with the varying needs of different businesses, which has played a crucial role in the company's growth and success.

Industry

Recruiting and staffing services

Company size

201 - 500 Employees

Headquarters location

Utica, MI, US

Year founded

2004

Social media

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