Remote Utilization Management Nurse

Job Type: Full-time
Schedule: Tuesday - Saturday OR Sunday - Thursday 8:00 AM – 5:00 PM (PST)
Location: Anywhere in the US, Remote (California RN or LVN license required)

Job Summary
MUST HAVE CALIFORNIA LICENSE. We are seeking a detail-oriented Utilization Management Nurse (Pre-Service / Prior Authorization Review) to join our growing clinical team. This role focuses on reviewing pre-certification requests for inpatient and outpatient services, ensuring patients receive the right care at the right time. You'll collaborate with providers, case managers, and medical directors to support high-quality, cost-effective care delivery.

This position is fully remote, but requires an active California RN or LVN license .

Responsibilities

• Review pre-service authorization (prior auth) requests for medical necessity using evidence-based guidelines (MCG, InterQual, or similar).
• Collaborate with providers, physicians, and medical directors on care determinations.
• Verify eligibility, benefits, and accuracy of submitted medical codes (ICD-10, CPT).
• Process requests within required turnaround times while documenting all activities accurately.
• Support appeals and grievances by providing clinical input when needed.
• Maintain professional communication with providers, patients, and internal staff.
• Assist with single-service agreements when services are out of network.
• Participate in team calls, case discussions, and process improvement initiatives.

Qualifications

Required:

• Active, unrestricted California LVN or RN license.
• 1+ year of experience with Medicare or Medicaid.
• Familiarity with utilization management, medical terminology, and coding.

Preferred (not required):

• 2+ years of experience in a managed care or hospital setting.
• Prior use of Milliman (MCG), InterQual, or CMS guidelines.
• Knowledge of Medicare Managed Care Plans.
• Associates or Bachelor's degree in Nursing.
• Certification such as CPHQ, ABQAURP, or Six Sigma.
• Strong critical thinking and problem-solving skills.
• Excellent written and verbal communication.
• Ability to prioritize multiple tasks and meet deadlines in a fast-paced environment.
• Proficiency in Microsoft Word, Excel, and Outlook.

What We Offer

• 100% remote position with a flexible schedule (Mon - Fri) or (Wed - Sun)
• Competitive salary and performance-based incentives.
• Full benefits package, including:
• Medical, dental, and vision coverage.
• 401(k) with employer contributions.
• Paid time off, personal days, and holidays.
• Life and disability insurance.
• Ongoing training and career development.

Job Type: Full-time

Pay: $90, $105,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Disability insurance
• Employee assistance program
• Employee discount
• Flexible schedule
• Flexible spending