Remote Utilization Review Nurse (OR)

Position Overview

Step into a role where your nursing expertise plays a central part in improving patient recovery and supporting efficient healthcare practices. As a Remote Utilization Review Nurse with an Operating Room (OR) focus, you'll evaluate medical records and treatment plans to ensure evidence-based care is being delivered appropriately and efficiently. This remote position enables you to apply your surgical nursing knowledge from the comfort of your own home, while opening doors to leadership development and making a meaningful impact.

Key Responsibilities

Medical Review Functions

• Conduct comprehensive utilization reviews of OR-related medical records to determine medical necessity and compliance with healthcare standards.
• Apply clinical criteria such as InterQual or MCG to assess service appropriateness and length of stay.

Collaborative Functions

• Collaborate with physicians, surgeons, case managers, and insurance providers to optimize treatment plans and improve cost-effectiveness.
• Participate in pre-certification, concurrent, and retrospective reviews for inpatient and outpatient surgical procedures.

Documentation and Compliance

• Document detailed clinical reviews and communicate determinations with clarity and accuracy.
• Identify patterns of over- or under-utilization, and escalate concerns to medical directors when necessary.
• Stay updated on clinical guidelines, payer policies, and changes in OR protocol that impact utilization review decisions.

Work Environment

This role is fully remote, allowing you to work from home while engaging in high-level collaboration with a multidisciplinary team. You’ll work with a dedicated team of professionals committed to elevating patient care through accurate utilization management. You'll benefit from a well-balanced workload that respects your independence and supports productivity. The supportive digital infrastructure ensures secure access to electronic health records and efficient communication tools, making virtual collaboration seamless and practical.

Tools and Technologies

To thrive in this position, proficiency with cloud-based clinical review systems is essential. You’ll be using:

• Electronic Medical Record (EMR) platforms such as Epic or Cerner
• Utilization review software like InterQual or MCG guidelines
• Secure communication systems, including HIPAA-compliant chat, telehealth tools, and remote conferencing platforms
• Internal portals for audit reporting, performance tracking, and knowledge-sharing among nursing peers

Required Qualifications

Minimum Credentials

• Active and unrestricted RN license valid in a compact state
• Minimum of three years of clinical nursing experience with significant exposure to surgical procedures and OR protocols
• At least two years of recent experience in utilization review, case management, or medical necessity auditing

Essential Competencies

• Deep understanding of clinical documentation practices and evidence-based criteria
• Ability to evaluate complex medical scenarios using critical thinking and sound clinical judgment
• Strong written communication skills to document determinations and collaborate professionally
• Comfortable working independently in a remote, results-driven setting

Preferred Attributes

• A bachelor's or advanced degree in nursing science or health administration
• Certification in Utilization Review (e.g., CCM, CPUR, or similar)
• Prior experience working with commercial, Medicare, or Medicaid payers
• Exposure to preauthorization workflows and appeals processes

Career Growth and Development

We prioritize ongoing learning and nurse-led innovation. As a Remote Utilization Review Nurse, you will be encouraged to:

• Lead peer case review sessions to refine clinical decision-making across the team
• Attend virtual conferences and workshops on utilization management trends and payer regulations
• Take part in quality improvement initiatives and organizational policy refinement
• Mentor junior nurses who are transitioning into remote clinical review roles

Your contributions directly support our commitment to clinical integrity, helping to reduce unnecessary procedures while safeguarding patient rights and ensuring accurate coverage.

Compensation and Benefits

This position offers a yearly salary of $87,946, along with a thoughtfully designed benefits package that includes:

• Remote work flexibility with provided equipment and IT support
• Comprehensive health, dental, and vision coverage
• Generous paid time off and wellness days
• Opportunities for bonus and incentive-based performance pay
• Annual education reimbursement for certifications or training

Impact and Mission Alignment

This position makes a meaningful contribution to advancing healthcare quality by aligning clinical decisions with ethical guidelines and ensuring financial responsibility. In this role, you serve as a guardian of patient advocacy and payer accountability, ensuring that every surgical treatment plan meets necessary standards without overburdening the healthcare system. With attention to detail, you influence policy, optimize operating room (OR) procedures, and strengthen a culture grounded in informed medical practices that serve all stakeholders.

Why Join Us

Visualize a career where your skills as a clinical professional are not only respected but consistently appreciated. Your work strengthens healthcare’s accessibility, quality, and long-term viability. And where your day-to-day work supports a larger vision of ethical, patient-centered medical review. If you're seeking a nursing role that offers remote flexibility, long-term growth, and daily purpose, this opportunity is designed for you.

Call to Action

Ready to take the lead in shaping better surgical care from wherever you work best? Join a purpose-driven team dedicated to clinical excellence and progressive care models. Submit your application and move forward in a remote nursing role that values your insights and drives real-world impact.