West Des Moines, IA · Remote
$90K - $110K/yr
We are seeking an experienced Regional MDS / PDPM / CMI / RAI Consultant to provide remote ... Review PDPM classifications, clinical documentation, diagnosis coding, and reimbursement accuracy
Quick apply
West Des Moines, IA · Remote
$90K - $110K/yr
We are seeking an experienced Regional MDS / PDPM / CMI / RAI Consultant to provide remote ... Review PDPM classifications, clinical documentation, diagnosis coding, and reimbursement accuracy
Des Moines, IA · Remote
$21 - $26.50/hr
Remote. We are seeking a compassionate and detail-oriented Bilingual RN Case Manager to join our ... Provide telephonic case management and utilization review for assigned consumers. * Develop ...
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Des Moines, IA · Remote
$21 - $26.50/hr
Remote. We are seeking a compassionate and detail-oriented Bilingual RN Case Manager to join our ... Provide telephonic case management and utilization review for assigned consumers. * Develop ...
Des Moines, IA · Remote
$21 - $26.50/hr
Remote. We are seeking a compassionate and detail-oriented Bilingual RN Case Manager to join our ... Provide telephonic case management and utilization review for assigned consumers. * Develop ...
Des Moines, IA · Remote
$21 - $26.50/hr
Remote. We are seeking a compassionate and detail-oriented Bilingual RN Case Manager to join our ... Provide telephonic case management and utilization review for assigned consumers. * Develop ...
Clive, IA · Remote
$80K - $90K/yr
This is a remote position. Seeking Registered Nurse for fully remote role to perform complex ... utilization/practice guidelines, clinical review judgment and when appropriate, monitor for ...
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Clive, IA · Remote
$80K - $90K/yr
This is a remote position. Seeking Registered Nurse for fully remote role to perform complex ... utilization/practice guidelines, clinical review judgment and when appropriate, monitor for ...
Des Moines, IA · Remote
$57.25 - $68.75/hr
Review prior authorization requests for accuracy, appropriateness, and clinical necessity. * Apply ... Prior authorization, utilization management, or managed care preferred - retail or hospital ...
Des Moines, IA · Remote
$57.25 - $68.75/hr
Review prior authorization requests for accuracy, appropriateness, and clinical necessity. * Apply ... Prior authorization, utilization management, or managed care preferred - retail or hospital ...
Davenport, IA · Remote
$51.75 - $62/hr
Review prior authorization requests for accuracy, appropriateness, and clinical necessity. * Apply ... Prior authorization, utilization management, or managed care preferred - retail or hospital ...
Davenport, IA · Remote
$51.75 - $62/hr
Review prior authorization requests for accuracy, appropriateness, and clinical necessity. * Apply ... Prior authorization, utilization management, or managed care preferred - retail or hospital ...
Davenport, IA · On-site +1
$50.75 - $62/hr
Review clinical documentation for medication coverage appeals and grievances. * Apply evidence ... Prior managed care or utilization management experience preferred - retail and hospital pharmacists ...
Davenport, IA · On-site +1
$50.75 - $62/hr
Review clinical documentation for medication coverage appeals and grievances. * Apply evidence ... Prior managed care or utilization management experience preferred - retail and hospital pharmacists ...
Des Moines, IA · On-site +1
$56.25 - $68.50/hr
Review clinical documentation for medication coverage appeals and grievances. * Apply evidence ... Prior managed care or utilization management experience preferred - retail and hospital pharmacists ...
Des Moines, IA · On-site +1
$56.25 - $68.50/hr
Review clinical documentation for medication coverage appeals and grievances. * Apply evidence ... Prior managed care or utilization management experience preferred - retail and hospital pharmacists ...
Iowa City, IA · On-site +1
$17 - $21.75/hr
Per policy, work arrangements will be reviewed annually and must comply with the remote work ... Problem solves with insurance utilization review nurses, medical directors, providers, and other ...
Iowa City, IA · On-site +1
$17 - $21.75/hr
Per policy, work arrangements will be reviewed annually and must comply with the remote work ... Problem solves with insurance utilization review nurses, medical directors, providers, and other ...
Iowa City, IA · On-site +1
$17 - $21.75/hr
Per policy, work arrangements will be reviewed annually and must comply with the remote work ... Problem solves with insurance utilization review nurses, medical directors, providers, and other ...
Iowa City, IA · On-site +1
$17 - $21.75/hr
Per policy, work arrangements will be reviewed annually and must comply with the remote work ... Problem solves with insurance utilization review nurses, medical directors, providers, and other ...
Lead operational governance activities across assigned Clubs, including creative review oversight ... Track and monitor Club marketing funding utilization to ensure compliance with Producer Agreements
Lead operational governance activities across assigned Clubs, including creative review oversight ... Track and monitor Club marketing funding utilization to ensure compliance with Producer Agreements
West Des Moines, IA · Remote
$63K - $95K/yr
Strong cost containment background, such as utilization review or managed care helpful ... Remote
West Des Moines, IA · Remote
$63K - $95K/yr
Strong cost containment background, such as utilization review or managed care helpful ... Remote
West Des Moines, IA · Remote
$62K - $93K/yr
Strong cost containment background, such as utilization review or managed care helpful ... Remote
West Des Moines, IA · Remote
$62K - $93K/yr
Strong cost containment background, such as utilization review or managed care helpful ... Remote
Des Moines, IA · Remote
$55K - $67K/yr
Interface with Admissions, Verification of Benefits, Utilization Review, and Clinical teams in ... li-remote Based on the nature of this role, you will need to complete several state background ...
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Des Moines, IA · Remote
$55K - $67K/yr
Interface with Admissions, Verification of Benefits, Utilization Review, and Clinical teams in ... li-remote Based on the nature of this role, you will need to complete several state background ...
West Des Moines, IA · Remote
$62K - $93K/yr
Strong cost containment background, such as utilization review or managed care helpful ... Remote
West Des Moines, IA · Remote
$62K - $93K/yr
Strong cost containment background, such as utilization review or managed care helpful ... Remote
West Des Moines, IA · Remote
$62K - $93K/yr
Strong cost containment background, such as utilization review or managed care helpful ... Remote
Quick apply
West Des Moines, IA · Remote
$62K - $93K/yr
Strong cost containment background, such as utilization review or managed care helpful ... Remote
West Des Moines, IA · Remote
$62K - $93K/yr
Strong cost containment background, such as utilization review or managed care helpful ... Remote
Quick apply
West Des Moines, IA · Remote
$62K - $93K/yr
Strong cost containment background, such as utilization review or managed care helpful ... Remote
Ability to read, review and understand support resources provided by the contact center and its ... Frequent utilization of manual dexterity and visualizing of computer screen * No unusual physical ...
Ability to read, review and understand support resources provided by the contact center and its ... Frequent utilization of manual dexterity and visualizing of computer screen * No unusual physical ...
West Des Moines, IA · Remote
$63K - $95K/yr
Strong cost containment background, such as utilization review or managed care helpful ... Remote
Quick apply
West Des Moines, IA · Remote
$63K - $95K/yr
Strong cost containment background, such as utilization review or managed care helpful ... Remote
Ability to read, review and understand support resources provided by the contact center and its ... Frequent utilization of manual dexterity and visualizing of computer screen * No unusual physical ...
Ability to read, review and understand support resources provided by the contact center and its ... Frequent utilization of manual dexterity and visualizing of computer screen * No unusual physical ...
$20.09 - $24.16
2% of jobs
$24.16 - $28.22
9% of jobs
$31 is the 25th percentile. Wages below this are outliers.
$28.22 - $32.29
21% of jobs
The median wage is $35.58 / hr.
$32.29 - $36.35
23% of jobs
$36.35 - $40.42
13% of jobs
$43.58 is the 75th percentile. Wages above this are outliers.
$40.42 - $44.48
10% of jobs
$44.48 - $48.54
8% of jobs
$48.54 - $52.61
5% of jobs
$52.61 - $56.67
5% of jobs
$56.67 - $60.74
2% of jobs
$60.74 - $64.80
2% of jobs
$20
$39
$64
To thrive as a Remote Utilization Review professional, you need a solid foundation in clinical knowledge, critical thinking, and an active RN or LPN license, often supported by experience in case management or prior authorization. Familiarity with medical coding (ICD-10, CPT), electronic health records (EHRs), and utilization management software is typically required, along with URAC or related certifications. Excellent communication, attention to detail, and strong organizational skills help you efficiently manage cases and coordinate with providers and payers. These skills ensure accurate assessments of medical necessity, compliance with regulations, and effective remote collaboration with healthcare teams.
A typical day for a Remote Utilization Review professional involves reviewing patient medical records, evaluating the necessity of proposed treatments against established guidelines, and collaborating with healthcare providers to gather additional information when needed. You will spend much of your time analyzing documentation, submitting recommendations, and ensuring that care authorization decisions align with payer policies and clinical best practices. Communication with case managers, physicians, and insurance representatives is frequent and essential. The work is generally independent and deadline-driven but requires strong teamwork and responsiveness through virtual meetings, emails, and calls.
A Remote Utilization Review job involves assessing medical records and treatment plans to ensure they meet insurance guidelines and medical necessity criteria. Professionals in this role, often nurses or healthcare specialists, work remotely to review patient care for cost-effectiveness and compliance with policies. They collaborate with healthcare providers, insurance companies, and case managers to approve or deny services based on established guidelines. This position requires strong analytical skills, knowledge of medical policies, and attention to detail.
$90K - $110K/yr
Full-time
Posted 15 days ago
Are you ready to make a change?
We are seeking an experienced Regional MDS / PDPM / CMI / RAI Consultant to provide remote reimbursement, MDS, PDPM, Case Mix Index, and RAI support to our long-term care and skilled nursing facilities.
This position will work primarily from home and provide regional oversight to ensure accurate MDS completion, proper PDPM classification, optimized reimbursement, accurate case mix, regulatory compliance, and strong interdisciplinary team processes. Quarterly travel to assigned facilities will be required for on-site audits, training, clinical reimbursement review, and team support.
This role is ideal for a highly organized MDS professional with strong knowledge of PDPM, RAI guidelines, CMI, care planning, Medicare documentation, and long-term care reimbursement systems.
Key Responsibilities
Provide regional oversight for MDS, PDPM, CMI, and RAI processes
Monitor timely and accurate MDS completion across assigned facilities
Review PDPM classifications, clinical documentation, diagnosis coding, and reimbursement accuracy
Support Case Mix Index improvement through accurate assessment and documentation
Audit MDS assessments for accuracy, compliance, and missed reimbursement opportunities
Review Medicare Part A documentation and skilled coverage support
Assist with Triple Check and Medicare meetings
Support facility MDS Coordinators, DONs, Administrators, and interdisciplinary teams
Review care plans for accuracy and alignment with MDS assessments
Monitor ARD schedules, assessment calendars, significant change assessments, and discharge assessments
Provide education and coaching to facility MDS and clinical teams
Assist with RAI Manual interpretation and regulatory compliance
Identify trends, risks, late assessments, coding errors, and reimbursement concerns
Participate in monthly or quarterly reimbursement reviews with regional leadership
Travel quarterly to assigned facilities for audits, training, and operational support
Qualifications
Active RN license required
Long-term care/skilled nursing experience required
MDS experience required
Strong knowledge of PDPM, RAI, CMI, Medicare, and Medicaid case mix processes
Experience with multi-facility MDS oversight preferred
RAC-CT certification preferred
Experience with Triple Check, Medicare meetings, care planning, and reimbursement audits preferred
Strong understanding of RAI Manual requirements
Ability to work independently from home
Strong communication, organization, auditing, and follow-through skills
Ability to travel quarterly to assigned facilities
Experience with PCC or similar electronic health record system preferred
Compensation & Benefits
Competitive salary or hourly rate
Primarily remote/work-from-home position
Quarterly travel reimbursement
Mileage reimbursement
Lodging and meal reimbursement when overnight travel is required
Licensure or certification reimbursement as approved
Opportunity to support multiple facilities and directly impact reimbursement accuracy, compliance, and clinical outcomes
