Utilization Review RN ( Remote- CA)

MUST RESIDE IN THE STATE OF CALIFORNIA

Job Summary
We are seeking a highly skilled and detail-oriented Utilization Review Registered Nurse (RN) to join our team remotely in California. The ideal candidate will have extensive experience in managed care, clinical documentation improvement, and utilization management. This role involves reviewing medical records, ensuring compliance with healthcare standards, and supporting appropriate patient care management across various settings including inpatient, outpatient, and home care. The RN will utilize advanced EMR/EHR systems such as Epic, Cerner, Athenahealth, and eClinicalWorks to facilitate accurate documentation review and case management. Strong knowledge of medical coding (ICD-9, ICD-10, CPT), anatomy, physiology, and healthcare regulations such as HIPAA is essential for success in this position.

Responsibilities

• Conduct comprehensive reviews of medical records and clinical documentation to determine medical necessity and appropriateness of care.
• Utilize clinical expertise to evaluate patient cases across inpatient, outpatient, ICU, PICU, NICU, and hospice settings.
• Apply knowledge of ICD-9, ICD-10, CPT coding, DRGs, and other medical coding standards to support accurate documentation review.
• Collaborate with healthcare providers to facilitate discharge planning, case management, and utilization management processes aligned with NCQA standards.
• Ensure compliance with Medicare regulations and other payer requirements such as Managed Care organizations.
• Use EMR/EHR systems including Epic, Cerner, Athenahealth, and eClinicalWorks for documentation review and data entry.
• Support clinical documentation improvement initiatives to enhance accuracy of medical records and coding.
• Maintain confidentiality of patient information in accordance with HIPAA regulations.
• Participate in ongoing education related to hospital standards such as Level I & II trauma centers or specialty areas like emergency medicine or pediatrics.

Requirements

• Valid Registered Nurse (RN) license in California.
• Proven experience in utilization review or utilization management within hospital or managed care environments.
• Critical care experience preferred; ICU or trauma center experience highly desirable.
• Strong knowledge of medical terminology, anatomy & physiology, ICD coding (ICD-9/ICD-10), CPT coding, DRGs, MDS, and clinical documentation improvement practices.
• Familiarity with EMR/EHR systems including Epic, Cerner, Athenahealth, eClinicalWorks; experience with health information management tools is a plus.
• Knowledge of Medicare regulations and NCQA standards for healthcare quality assurance.
• Excellent analytical skills with attention to detail for documentation review and case assessment.
• Ability to work independently remotely while managing multiple cases efficiently.
• Strong understanding of HIPAA compliance and patient confidentiality protocols. This position offers an excellent opportunity for experienced RN professionals seeking a remote role that combines clinical expertise with healthcare management functions in a dynamic environment committed to quality patient care.

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Pay: From $45.00 per hour

Expected hours: 40.0 per week

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Vision insurance

Application Question(s):

• Do you Reside in California
• Do You have an Active California RN License

Work Location: Remote

Salary : $45