Nurse RN 3

Fully REMOTE

Must Reside in California

Monday-Friday 8-5
Nurse RN 3

Job Summary

The Nurse RN 3 performs utilization review activities for Medicare members, ensuring appropriate levels of care, effective discharge planning, and compliance with regulatory and accreditation standards. This role requires strong clinical judgment, coordination with interdisciplinary teams, and maintenance of productivity and quality metrics in a telework environment.

Responsibilities

• Perform prospective, concurrent, and retrospective utilization reviews and first-level determination approvals using evidence-based guidelines, policies, and nationally recognized clinical criteria for Medicare members.
• Ensure discharge planning at appropriate levels of care based on member needs and acuity.
• Coordinate durable medical equipment and post-service needs to support quality and cost-effective discharge planning.
• Prepare and present cases to the Medical Director for oversight and necessity determinations.
• Communicate determinations to providers and members in alignment with state, federal, and accreditation requirements.
• Develop and review member-centered documentation and correspondence that reflect determinations in compliance with regulatory and accreditation standards.
• Identify potential quality-of-care issues, service delays, or treatment delays and intervene as clinically appropriate.
• Refer members to Case Management when acute inpatient needs may affect discharge.
• Participate in staff meetings, clinical rounds, and weekly huddles.
• Maintain quality and productivity metrics for all casework.
• Maintain a HIPAA-compliant workspace in a telework environment.

Requirements

• Associate’s degree in nursing required; bachelor’s degree in nursing preferred.
• Minimum of 2 years of utilization management experience.
• Minimum of 5 years of recent direct inpatient hospital patient care experience.
• Strong clinical background with demonstrated critical thinking skills.
• Strong communication skills, both written and verbal.

Proficiency with Windows, Excel, and Outlook.

• Ability to maintain HIPAA compliance in a remote work setting.
• Valid and active nursing license (as required by role and jurisdiction).
• No history of poor computer skills, unexplained multiple short-term roles, or lack of clinical experience.

Skills

• Strong communication and critical thinking abilities.
• Utilization management and medical necessity review.
• Inpatient hospital clinical expertise.
• Discharge planning and care coordination.
• Ability to identify quality-of-care issues and intervene appropriately.
• Proficiency in common office software (Windows, Excel, Outlook).
• Effective collaboration with multidisciplinary clinical care
• Strong documentation and correspondence skills.
• Ability to work independently and meet productivity and quality metrics.

Summary Qualification

• Registered Nurse with an associate’s degree in nursing (bachelor’s degree preferred).
• Must have at least 5 years of direct inpatient hospital clinical experience.
• Must have at least 2 years of utilization management experience.
• Experience working with Medicare members or similar populations.
• Demonstrated ability to perform utilization review and discharge planning.
• Comfortable working in a remote, HIPAA-compliant environment.

Wollborg Michelson Recruiting is an Equal Opportunity Employer and prohibits discrimination of any kind. We ensure job offers are made based of one’s employment experience, skills, and qualifications, regardless of race, gender, ethnic origin, or any other classification protected by law. All applicants must furnish proper identification to prove their legal right to work in the US upon a job offer. We participate in E-Verify to confirm one’s right to work in the US. Wollborg Michelson Recruiting does not provide sponsorship for an employment-based visa status.

Pay: From $52.28 per hour

Benefits:

• Health insurance

Work Location: Remote

Salary : $52