RN Utilization Management Reviewer - Remote (WA, OR, or AK)
Description Join PeaceHealth in advancing compassionate, mission-driven care from wherever you are. PeaceHealth is looking for a skilled and motivated Registered Nurse Utilization Management (UM) Reviewer to join our dedicated team in a Full Time, Day Shift (1.0 FTE) role. If you enjoy analytical work and are energized by helping ensure patients receive the right care at the right time, this remote opportunity may be the perfect next step in your nursing career. Why You’ll Love This Role As a Utilization Management Reviewer at PeaceHealth, you will play a key part in supporting safe, high-quality, and efficient patient care across our healthcare system. This position centers on concurrent and retrospective UM reviews, leveraging clinical expertise, payer policy knowledge, and technology tools to guide patient status determinations and promote appropriate utilization of hospital resources. You’ll work fully remote*, with PeaceHealth-provided computer equipment—empowered by a collaborative team, supportive leadership, and a strong organizational commitment to diversity, cultural humility, and caregiver well-being.
- Must reside in Washington, Oregon, or Alaska. PeaceHealth will provide the caregiver with necessary computer equipment. It is the responsibility of the caregiver to provide Internet access.
PeaceHealth’s Total Rewards package supports your physical, emotional, financial, social, and spiritual wellbeing. Benefits include:
- Pay Range: $48.52 – $72.78/hour
- Full medical, dental, and vision coverage
- 403(b) retirement plan with employer base and matching contributions
- Paid time off and paid disability & life insurance (with buy-up options)
- Tuition reimbursement and continuing education support
- Robust wellness benefits, EAP, and expanded mental health programs
- A culture grounded in Inclusivity, Respect for Diversity, and Cultural Humility
What You’ll Do
- Coordinate accurate patient status identification and documentation
- Ensure correct admission status and reimbursement through certification and clinical review
- Gather additional clinical documentation to validate treatment plans and level of care
- Collaborate closely with physicians, clinicians, and multidisciplinary teams
- Apply UM criteria using the Xsolis Dragonfly™ platform and PeaceHealth Care Level Score tools
- Conduct pre-admission status reviews in the ED, patient access areas, and elective settings
- Communicate with third-party payers regarding medical necessity and discharge progress
- Support denial and appeal processes; refer cases for physician advisor review when appropriate
- Participate in UM Committee work, quality initiatives, and performance improvement
- Identify DRGs with complications/comorbidities and recommend documentation improvements
- Promote responsible hospital resource utilization, length-of-stay optimization, and care efficiency
- Perform other duties as needed to support UM and organizational goals
What You Bring Education
- Required: Bachelor of Science in Nursing (BSN)
- Preferred: Master of Science in Nursing (MSN)
Experience
- 3+ years of acute care hospital experience with strong clinical knowledge
- In-depth understanding of Medicare/Medicaid UM regulations, RAC, QIO, MAC, and denial/appeals processes
- Preferred: Prior experience in utilization management or case management
Credentials
- Active RN license in your state of residence (WA, OR, or AK)
Ready to Make a Meaningful Impact? Bring your clinical expertise, attention to detail, and passion for patient advocacy to a mission-driven healthcare system that believes in caring for caregivers as much as patients. For full consideration, please attach a current resume with your application. PeaceHealth is an EEO Affirmative Action Employer/Veterans/Disabled following all applicable state, local, and federal laws. Apply tot his job Apply To this Job