This position is posted by Jobgether on behalf of a partner company. We are currently looking for a Sr. Virtual Utilization Review Specialist in United States.
This role plays a critical part in ensuring appropriate healthcare utilization and optimizing patient outcomes within a fast-paced, data-informed clinical environment. The Sr. Virtual Utilization Review Specialist evaluates medical necessity, supports care coordination, and helps ensure that patients receive the right level of care at the right time. Working remotely, the role collaborates closely with physicians, care managers, financial teams, and payers to support both clinical quality and revenue integrity. It requires strong clinical judgment, analytical thinking, and the ability to interpret complex clinical criteria and payer guidelines. The position also involves contributing to denial prevention and appeals processes while maintaining compliance with regulatory standards. Ideal candidates thrive in autonomous settings while staying highly connected to multidisciplinary teams focused on improving patient and system-wide outcomes.
Accountabilities:- Conduct medical necessity and utilization reviews for inpatient and observation cases using approved clinical criteria, ensuring appropriate level-of-care determinations and timely documentation.
- Identify potential over- or under-utilization of healthcare services and collaborate with physicians, care managers, and financial teams to address barriers to patient progress.
- Support denial management activities, including coordinating peer-to-peer reviews, tracking appeal outcomes, and analyzing denial trends to reduce revenue leakage.
- Collaborate with interdisciplinary teams to ensure accurate communication of review outcomes and to facilitate appropriate patient care transitions.
- Maintain accurate records within revenue cycle and clinical systems, ensuring compliance with regulatory, payer, and organizational standards.
- Monitor quality indicators, CMS guidelines, and readmission risks while contributing to process improvement and revenue integrity initiatives.
Requirements:
- Active and unrestricted RN or LPN license (RN compact license preferred).
- Bachelor’s degree in Nursing or equivalent clinical experience.
- Minimum of 3 years of nursing experience in an acute care setting preferred.
- Prior experience in utilization review, discharge planning, or medical necessity review strongly preferred.
- Strong knowledge of clinical criteria, quality improvement processes, MS-DRGs, and payer guidelines.
- Excellent clinical assessment, critical thinking, and organizational skills in a high-volume environment.
- Strong communication and interpersonal skills with the ability to engage physicians, payers, and multidisciplinary teams effectively.
- Ability to work independently in a remote setting with high attention to detail and time management.
- Proficiency in clinical and revenue cycle systems, with openness to digital tools and innovation.
Benefits:
- Competitive pay range: $32.65 – $53/hour depending on license type and experience.
- Performance-based bonus incentives and recognition programs.
- Paid certifications and tuition reimbursement for professional development.
- Comprehensive benefits package including medical, dental, vision, life insurance, and disability coverage.
- Retirement savings plan and financial wellness support.
- Flexible remote work with structured schedules and occasional onsite requirements when needed.
- Paid time off, holidays, and work-life flexibility programs.
- Strong culture of growth, collaboration, and continuous learning in a healthcare-focused environment.
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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