Springfield, IL · Remote
$40 - $42/hr
This is a fully remote role but candidates must have a valid RN license in Illinois*** Position Purpose: Care Review Clinician works with the Utilization Management team primarily responsible for ...
New
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Springfield, IL · Remote
$40 - $42/hr
This is a fully remote role but candidates must have a valid RN license in Illinois*** Position Purpose: Care Review Clinician works with the Utilization Management team primarily responsible for ...
New
Manage a caseload effectively, including conducting case management and utilization review updates ... Experience working in a remote setting is preferred. Preferred Experience * Minimum of 2 years of ...
New
Manage a caseload effectively, including conducting case management and utilization review updates ... Experience working in a remote setting is preferred. Preferred Experience * Minimum of 2 years of ...
New
Medicaid Business / QA Analyst * 7-12+ Month Contract | Remote | No ThirdParty Firms | Medicaid SME ... Review inbound data from core systems (eligibility, provider, claims, managed care) for accuracy ...
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Medicaid Business / QA Analyst * 7-12+ Month Contract | Remote | No ThirdParty Firms | Medicaid SME ... Review inbound data from core systems (eligibility, provider, claims, managed care) for accuracy ...
$21.20 - $25.49
2% of jobs
$25.49 - $29.78
9% of jobs
$32.71 is the 25th percentile. Wages below this are outliers.
$29.78 - $34.07
21% of jobs
The median wage is $37.54 / hr.
$34.07 - $38.36
23% of jobs
$38.36 - $42.65
13% of jobs
$45.98 is the 75th percentile. Wages above this are outliers.
$42.65 - $46.93
10% of jobs
$46.93 - $51.22
8% of jobs
$51.22 - $55.51
5% of jobs
$55.51 - $59.80
5% of jobs
$59.80 - $64.09
2% of jobs
$64.09 - $68.38
2% of jobs
$21
$41
$68
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.
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.
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.
The most popular types of Utilization Review jobs in Springfield, IL are:
For Remote Utilization Review jobs in Springfield, IL, the most frequently searched job titles are:
The top searched job categories for Remote Utilization Review jobs in Springfield, IL are:
Cities near Springfield, IL with the most Remote Utilization Review job openings:
$40 - $42/hr
Full-time
Posted 3 days ago
New
AltaStaff is a staffing agency currently looking for a Care Review Clinician I to work with our Managed Care Client!
Pay Rate: $40 - 42.00 hourly
Schedule: Monday-Friday 9am-5:30pm CST, Rotating Saturday 7-11am CST, Rotating Holidays
***This is a fully remote role but candidates must have a valid RN license in Illinois***
Position Purpose: Care Review Clinician works with the Utilization Management team primarily responsible for medical necessity/utilization review aimed at providing members with the right care.
Assess and analyze clinical service requests (e.g., surgeries, outpatient therapies, DME) using evidence-based MCP/MCG criteria.
Verify member benefits and eligibility and Process prior authorization determinations within regulatory timelines
Collaborate with multidisciplinary teams
Completes/reviews Authorizations, reviewing faxes that can be 50-100 pages long
Will be expected to manage 25-30 cases successfully daily.
Should be able to quickly and accurately determine whether the criteria meet medical necessity.
Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review.
Assesses services for Molina Members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and
guidelines.
Provides concurrent review and prior authorizations (as needed) according to Molina policy for Molina members as part of the Utilization Management team.
Additional duties assigned
Education/Experience:
RN license in IL required
Must have 2+ years clinical practice experience (hospital, case management, utilization management)
Must have 1-3+ years of hospital or medical clinic, utilization review
Must have 2-3 years of Prior Authorization OR Med-Surg experience; Familiarity with Inpatient Medical Necessity
Must have solid experience within a clinical setting as RN’s must be able to use their knowledge to extrapolate key information during the authorization process
If you've applied and would like to view your application status, please visit: https://altastaff.zenople.com/login/ALTA
AltaStaff is an Equal Employment Opportunity Employer. We provide equal employment opportunities to all qualified applicants for employment without regard to age, race, color, creed, religion, sex, marital status, national origin, ancestry, citizenship, disability, veteran status, sexual orientation, or any other protected status, in accordance with applicable federal, state, and local laws.
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Sourced by ZipRecruiter
51 - 200 Employees
Chicago, IL, US
2007