Utilization Management-RN

Utilization Management Appeals Nurse – RN | Remote

Job Type: Full-Time
Work Arrangement: 100% Remote
Schedule: Monday–Friday, 8-hour shifts between 6:00 AM–6:00 PM EST

Job Summary

We are hiring an experienced Utilization Management Appeals Nurse (RN) to join our remote healthcare team. This position is ideal for a Registered Nurse with strong clinical experience who is interested in applying their clinical judgment, medical record review, utilization management, clinical documentation, and professional writing skills outside of the traditional bedside setting.

The Utilization Management Appeals Nurse is responsible for reviewing medical records and denial documentation, extracting relevant clinical information, and developing accurate, well-supported medical necessity appeals and appeal letters on behalf of healthcare provider clients.

The ideal candidate is a highly organized, self-directed Registered Nurse (RN) with excellent written communication skills who can work independently in a fast-paced healthcare environment while meeting quality and productivity expectations.

Key Responsibilities

• Perform detailed medical record reviews and review healthcare insurance denial documentation.

• Identify, analyze, and extract pertinent clinical and patient information.

• Evaluate clinical documentation and denial rationale using critical thinking and clinical judgment.

• Prepare clear, concise, accurate, and defensible clinical appeal letters.

• Develop medical necessity appeals using appropriate clinical information and supporting documentation.

• Utilize nationally recognized clinical criteria and guidelines, including MCG/IQ when applicable.

• Incorporate relevant medical literature and clinical evidence into appeal documentation.

• Follow approved appeal templates, processes, policies, and departmental guidelines.

• Ensure appeal letters demonstrate appropriate grammar, organization, clinical reasoning, and attention to detail.

• Complete assigned cases within established turnaround times while maintaining high-quality work.

• Collaborate with physicians, Appeals leadership, operations, intake teams, and other healthcare professionals.

• Follow all applicable company policies, procedures, quality standards, scheduling requirements, and productivity expectations.

• Work independently while effectively managing multiple cases and competing priorities.

Required:

• Current, active Registered Nurse (RN) license.

• 3+ years of bedside nursing experience.

• Recent or relevant experience in one or more of the following:

  • Adult Emergency Department (ED)

  • Telemetry

  • Intensive Care Unit (ICU)

  • Critical Care Unit (CCU)

• Strong clinical assessment and critical-thinking skills.

• Excellent written communication and professional writing skills.

• Strong attention to detail and ability to accurately interpret medical records.

• Proficiency with Microsoft Word and standard computer applications.

• Ability to work independently in a fast-paced healthcare environment.

• Ability to manage workload, meet deadlines, and maintain quality and productivity standards.

Preferred Qualifications

• Previous Utilization Management (UM) experience.

• Previous Utilization Review (UR) experience.

• Prior healthcare appeals or clinical appeals experience.

• Experience writing appeal letters or medical necessity appeals.

• Familiarity with MCG Guidelines.

• Familiarity with IQ Guidelines.

• Experience with clinical criteria, medical necessity review, or insurance denials.

• Experience performing clinical documentation and medical record review.

Ideal Candidate

This role is a strong fit for an RN who has worked in ED, ICU, CCU, Telemetry, or other acute-care settings and wants to transition their clinical expertise into Utilization Management, Utilization Review, Appeals, or Clinical Review.

Successful candidates will demonstrate:

• Strong clinical knowledge and nursing judgment

• Excellent written and verbal communication

• Strong medical terminology and documentation skills

• Critical thinking and analytical abilities

• Exceptional attention to detail

• Ability to research and interpret clinical information

• Strong time-management and organizational skills

• Ability to work independently in a remote environment

• Comfort working in a high-volume, deadline-driven healthcare setting

Work Schedule

• Remote / Work from Home

• Monday–Friday

• 8-hour shifts

• Schedule will fall between 6:00 AM and 6:00 PM EST

Apply Today

If you are a Registered Nurse (RN) with acute-care experience in ED, Telemetry, ICU, or CCU and are interested in Utilization Management, Utilization Review, Medical Record Review, or Clinical Appeals, we encourage you to apply.

Join our team as a Utilization Management Appeals Nurse and use your clinical expertise, critical-thinking skills, and professional writing abilities to support high-quality, defensible healthcare appeals.