This position is posted by Jobgether on behalf of a partner company. We are currently looking for a Utilization Management RN in the United States.

This role is central to ensuring members receive the most appropriate, effective, and timely care by applying clinical expertise to utilization review processes. You will evaluate medical necessity using established criteria, policies, and clinical guidelines while coordinating closely with providers, members, and interdisciplinary teams. Operating in a fully remote environment, you will contribute to care decisions that directly impact patient outcomes and healthcare quality. The position requires strong clinical judgment, attention to detail, and the ability to navigate complex care scenarios. You will collaborate within a structured utilization management framework aligned with organizational goals and regulatory standards. This is a highly impactful role at the intersection of clinical care, coordination, and health plan operations.

Accountabilities

In this role, you will apply clinical nursing expertise to review and evaluate treatment requests, ensuring services meet medical necessity criteria and align with established guidelines and policies. You will collaborate with providers and members to facilitate appropriate care pathways and support timely decision-making. Key responsibilities include:

Conducting utilization reviews and applying clinical criteria to determine appropriateness of services and levels of care
Coordinating and communicating with providers, members, and internal teams to support care planning and treatment decisions
Documenting and maintaining accurate clinical assessments and utilization determinations in accordance with regulatory standards
Supporting care coordination efforts and escalating complex cases as needed
Participating in departmental processes aligned with organizational and compliance requirements
Contributing to consistent application of utilization management policies and procedures

Requirements

This role requires a strong clinical foundation in acute care nursing and the ability to apply clinical judgment in a structured review environment. Candidates should be comfortable working independently in a remote setting while maintaining accuracy and compliance in all documentation and decisions.

Active Registered Nurse (RN) license in a compact state, with eligibility for additional licensure as required
Minimum 3+ years of acute care experience (Medical-Surgical, Cardiac, Pulmonary, or Critical Care)
Strong clinical assessment and critical thinking skills in high-acuity environments
Ability to interpret medical records, clinical criteria, and utilization guidelines
Preferred experience in utilization management, health plan, Medicare, or Medicaid environments
BSN or bachelor’s degree in nursing or related field preferred
Strong communication, collaboration, and documentation skills
Ability to work independently, manage workload, and adapt to rotating schedules including holidays if required

Benefits

Competitive annual salary ranging from $71,100 to $97,800, based on experience and location
Performance-based bonus incentive plan eligibility
Medical, dental, and vision insurance coverage
401(k) retirement savings plan
Paid time off, including holidays, parental leave, and volunteer time
Short-term and long-term disability coverage
Life insurance and additional wellness benefits
Remote work flexibility with required home office standards and support equipment where applicable

How Jobgether works:

We use an AI-powered matching process to ensure your application is reviewed quickly, objectively, and fairly against the role's core requirements. Our system identifies the top-fitting candidates, and this shortlist is then shared directly with the hiring company. The final decision and next steps (interviews, assessments) are managed by their internal team.

We appreciate your interest and wish you the best!

Why Apply Through Jobgether?

Data Privacy Notice: By submitting your application, you acknowledge that Jobgether will process your personal data to evaluate your candidacy and share relevant information with the hiring employer. This processing is based on legitimate interest and pre-contractual measures under applicable data protection laws (including GDPR). You may exercise your rights (access, rectification, erasure, objection) at any time.

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Utilization Management RN

Requirements

Benefits

Remote Healthcare Jobs