JOB DESCRIPTION
What does a utilization review nurse do?
A utilization review (UR) nurse checks whether a patient's admission, length of stay or requested service is medically necessary by comparing the clinical record with review criteria. When a case doesn't fit, the nurse refers it to a physician reviewer. In hospitals, Medicare rules give the "not medically necessary" decision to the utilization review committee, which must include at least two physicians, after it consults the patient's own practitioner.
- Typical dutiesFrom a real remote health-plan posting: review service requests against evidence-based clinical guidelines, run prior-authorization reviews, refer cases to medical directors and follow utilization management policies
- In hospitalsMedicare requires a UR plan that reviews the medical necessity of admissions, the duration of stays and professional services
- Typical requirementsAn active, unrestricted RN license in the state of practice. The posting we checked also asks for at least 2 years of hospital acute care, inpatient review or prior-authorization experience
- Nice to haveThe same posting prefers CPHM certification and experience with MCG criteria
Sources: Molina Healthcare remote care review clinician posting, checked Oct 30, 2026; 42 CFR 482.30.
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WHAT IT IS
1. Is this care medically necessary?
- That's the question UR nurses answerFor admissions, length of stay and services
- Every Medicare hospital must do itFederal rules require a utilization review plan
- Insurers hire UR nurses tooSome are fully remote
A DAY ON THE JOB
2. What the work looks like
- Read the chart for the admission or stay
- Check it against the review criteria
- Document it, and flag what doesn't fit
- Bring in the physician reviewer
- Coordinate with case management
WHO DECIDES
3. Nurses review. Physicians decide
- A "not medically necessary" callBelongs to the hospital's UR committee, which includes at least two physicians
- The patient's doctor speaks firstThe committee must consult them before deciding
Source: 42 CFR 482.30, Medicare hospital conditions of participation.
HOW TO GET THERE
4. Your path in
- An RN licenseActive and unrestricted
- Bedside experienceYou'll be judging the kind of care you've already given
- Certification, laterCCM: an RN license plus 12 to 24 months of case management work
Certification: Commission for Case Manager Certification (CCMC).
REMOTE RULES
5. Remote still means licensed
- Licensed where the patient isThe rule for nursing services, including from home
- A compact license helpsIt covers patients in other NLC states
- Real exampleA remote health-plan UR job that requires a California license
Sources: NCSBN Nurse Licensure Compact; a Molina Healthcare posting, checked Oct 6, 2026.
SPOT A SCAM
6. Remote job red flags
- They ask you to pay for the job, training or equipment
- They send a check and ask you to send part of it back
- They promise big money for little work
- Honest employers never do these
Source: FTC, Job Scams. Checked Oct 6, 2026.
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