Remote Utilization Review RN Overview • The Remote Utilization Review RN will perform utilization management tasks for acute-care patients across various settings, ensuring compliance with regulatory standards. • Work collaboratively within a centralized, fully remote Utilization Management team supporting multiple facilities and diverse service lines. • Assess medical necessity using evidence-based criteria and provide recommendations for appropriate care levels. • Utilize Epic for clinical documentation and review, ensuring accurate and timely record-keeping. • Apply Medicare regulations, including the 2-Midnight Rule, and other utilization management requirements. • Engage with interdisciplinary teams, including physicians, case managers, and payers, to optimize patient care coordination. • This role offers a flexible remote work environment with adherence to Pacific Standard Time hours. • Candidates will rotate among supported facilities based on departmental needs, ensuring comprehensive coverage. • This position is an auto-offer opportunity, providing streamlined hiring for qualified candidates. Remote Utilization Review RN Key Responsibilities & Duties • Perform admission, concurrent, continued-stay, retrospective, and pre-certification reviews for acute-care patients. • Determine medical necessity using InterQual criteria and review clinical documentation to support care decisions. • Collaborate with interdisciplinary teams, including physicians, case managers, and payers, to optimize patient outcomes. • Apply knowledge of CMS, HIPAA, DRGs, ICD-10, CPT, and other regulatory standards in daily operations. • Utilize Epic for clinical documentation, ensuring accuracy and compliance with utilization management processes. • Support care coordination and resource utilization across multiple facilities and service lines. • Manage UM processes involving CC44s, ABNs, HINNs, MCSNs, and related regulatory requirements. • Flexibly rotate among supported facilities based on departmental needs and service line requirements. • Adhere to California labor laws regarding meal periods, rest breaks, and overtime regulations. Remote Utilization Review RN Job Requirements • Active California RN license and Associate of Science (AS) degree in nursing. • Minimum 3 years of acute-care utilization management experience in a hospital setting. • Proficiency with InterQual criteria and recent Epic experience within the last 6–12 months. • Strong knowledge of Medicare regulations and utilization management processes. • Experience with HMOs, IPAs, and payer structures, including admission and concurrent reviews. • Ability to work independently in a fully remote environment, adhering to Pacific Standard Time hours. • Flexibility to rotate between four facilities and service lines based on departmental needs. • Preferred experience includes prior authorization, Medi-Cal knowledge, and ICD-10 coding familiarity. • Ability to work every other weekend throughout the contract duration.