Utilization Review Nurse RN or LVN - Full Remote

Utilization Review Nurse – RN or LVN (Remote, $43/hr)

Join one of the nation’s leading managed care organizations, committed to transforming health care for underserved communities. Our client is a mission-driven health plan known for delivering accessible, high-quality care to millions of members. With a reputation for innovation and collaboration, they’re looking for compassionate, skilled clinicians to help ensure members receive the right care at the right time — every time.

We are seeking experienced Registered Nurses (RNs) or Licensed Vocational/Practical Nurses (LVNs/LPNs) with prior authorization and/or behavioral health utilization management experience to join a dedicated Utilization Management (UM) team. This is a fully remote, full-time opportunity starting in September 2025.

Position Details

Pay Rate: $43.00 per hour

Schedule: Monday to Friday, 8:00 AM – 5:00 PM (1-hour lunch)

Work Location: 100% remote

Licensure: Must hold an active, unrestricted RN or LVN license in Ohio or a compact state. Preference for Ohio residents and licenses.

Position Summary

The Utilization Review Nurse is responsible for inpatient and outpatient medical necessity review, prior authorizations, and other UM activities. The goal is to ensure members receive appropriate, cost-effective, and timely care while supporting compliance with regulatory standards and promoting positive health outcomes.

Key Responsibilities

Perform concurrent review and prior authorization assessments per company policy

Evaluate member eligibility, benefits, and appropriate level of care

Participate in interdepartmental collaboration (Behavioral Health, Long-Term Care, etc.)

Document and maintain productivity and quality standards

Assist in onboarding and mentoring new team members

Consult regularly with medical directors and escalate as needed

Represent the organization professionally with internal and external stakeholders

Adhere to HIPAA, safety, and ethical standards in daily operations

Required Qualifications

Education: Completion of an accredited Registered Nursing or Vocational Nursing program (comparable experience/education combinations may be considered)

Experience:

Minimum 2 years UM or case management in a managed care organization

Experience with prior authorizations and/or behavioral health outpatient services

Licensure: Active, unrestricted RN or LVN license in Ohio or a compact state. Preference to Ohio residents and licenses.

Technical Skills:

Familiarity with InterQual criteria and UM software

Microsoft Office proficiency (Word, Excel, Outlook)

Additional Skills:

Strong communication, organization, and multitasking

Knowledge of NCQA and regulatory standards

Ability to work independently and meet deadlines in a fast-paced environment