RN, Utilization Management (Clinical Claims Review)

About This Opportunity

We are representing a confidential health insurance organization seeking an RN for Utilization Management and clinical claims review. This remote position allows you to use your nursing expertise to coordinate care decisions, assess medical necessity, and support members across the country.

Our client is looking for a licensed RN with strong clinical judgment and prior authorization or utilization management experience to join their care coordination team. You'll interpret clinical criteria, communicate with providers and members, and ensure appropriate care delivery.

Responsibilities

• Review and assess medical necessity for requested services using established clinical criteria
• Coordinate and communicate with healthcare providers, members, and other stakeholders to facilitate care decisions
• Apply clinical nursing knowledge to interpret medical documentation and determine appropriate courses of action
• Document clinical reviews and communicate benefit administration determinations clearly and professionally
• Navigate multiple healthcare systems and platforms to manage case reviews efficiently
• Support organizational goals around improving member experiences and care quality

What We're Looking For

Required:

• Active Registered Nurse (RN) license in an Enhanced Nurse Licensure Compact (eNLC) state with no disciplinary actions
• Ability to obtain and maintain multiple state RN licenses
• 3+ years of experience in prior authorization, claims review, utilization management, or similar healthcare/health insurance roles involving medical necessity assessment
• 3+ years of direct nursing experience in Medical-Surgical, Cardiac, Pulmonary, Maternity/Obstetrics, or Critical Care
• Clinical experience in acute care, skilled nursing, rehabilitation, or similar healthcare settings
• Intermediate to advanced proficiency with Microsoft Office (Word, Outlook, Excel) and ability to work across multiple platforms
• Reliable home internet: minimum 25 Mbps download, 10 Mbps upload (wired cable or DSL preferred)
• Dedicated workspace that protects member PHI and HIPAA compliance

Preferred:

• Bachelor's degree in Nursing (BSN) or related healthcare field
• Previous experience with a health plan, managed care organization, or health insurance provider
• Experience supporting Medicare or Medicaid populations
• Bilingual proficiency in Spanish and English

Schedule: Monday–Friday, 8:00 AM–5:00 PM with occasional overtime as needed. Fully remote nationwide with possible occasional travel for training.

How We Work With You

Candidates apply directly through Get A Job.ai. Our recruiting team will conduct an initial screening to understand your background and career goals. Qualified candidates are then presented to our client for consideration. Please do not contact the hiring organization directly—all communication is managed through our talent team to ensure a smooth, professional process.

Pay

Pay via Get A Job.ai: $71,100–$97,800 per year, depending on location and experience. This role is also eligible for performance-based bonus incentives.

Equal Employment Opportunity: Get A Job.ai is committed to inclusive hiring practices and does not discriminate on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, or any other protected characteristic.