Job Description

Registered Nurse – Utilization Review (Acute Care Experience Required)

Location: Fully remote (PA RN License Required)

Schedule: Monday – Friday, 8:45 AM – 5:00 PM; required to work every 4th Saturday

Position Overview:

We are seeking a skilled and detail-oriented Registered Nurse (RN) with a valid PA license to join our team in a Utilization Review capacity. This position is ideal for an RN with direct acute hospital experience or prior work in insurance utilization review. This is not a Case Management or Home Care nursing role—applicants must have hands-on acute hospital experience to be considered.

Key Responsibilities:

• Conduct clinical reviews to determine medical necessity and appropriateness of care
• Apply evidence-based criteria to assess patient treatment plans and services
• Collaborate with healthcare providers and insurance partners to ensure efficient, quality patient care
• Document review findings accurately and in a timely manner
• Maintain compliance with internal and external regulatory standards

Required Qualifications:

• Active and unrestricted PA RN license
• 3–5 years of recent direct care experience in an acute hospital setting (ICU, ED, Med/Surg, etc.)
• OR prior experience in insurance utilization review or hospital-based utilization management
• Strong clinical judgment and knowledge of hospital workflows
• Proficient in using clinical review tools and electronic health records

Preferred Experience:

• Prior work in payer-side utilization review is highly desirable
• Familiarity with InterQual or Milliman criteria

Work Schedule:

• Monday through Friday, 8:45 AM – 5:00 PM
• Required to work every 4th Saturday of the month

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