Utilization Review Nurse

About the Role

Title: Utilization Review Nurse, Remote

Location: Remote

Job Description:

Sidecar Health is redefining health insurance. Our mission is to make excellent healthcare affordable and attainable for everyone. We know that to accomplish this lofty mission, we need driven people who will make things happen.

The passionate people who make up Sidecar Health’s team come from all over, with backgrounds as tech leaders, policy makers, healthcare professionals, and beyond. And they all have one thing in common—the desire to fix a broken system and make it more personalized, affordable, and transparent.

If you want to use your talents to transform healthcare in the United States, come join us!

About the Role 

As a Utilization Review Nurse, you'll play a critical role in ensuring our members receive high-quality, medically necessary care. You will assess upcoming services and Good Faith Estimates to determine clinical appropriateness and apply established guidelines, such as MCG, to support coverage decisions. You’ll also draft clear, member-facing letters aligned with Sidecar Health policy, helping our members understand their benefits and options. 

Must reside in Florida, Georgia, Minnesota, North Carolina, Ohio, Texas, Utah

Key Responsibilities: 

• Apply Milliman Care Guidelines (MCG) to assess medical necessity and appropriateness of treatments 

• Review medical records, Good Faith Estimates, and prebills to evaluate scheduled care and identify potential gaps (e.g., labs, radiology, pre-op) 

• Evaluate claims, reconsiderations, and appeals to support accurate coverage determinations and ensure compliance with balance billing protections 

• Draft clear, member-facing letters outlining benefit decisions and relevant considerations 

• Collaborate with providers, vendors and internal stakeholders to gather necessary clinical information for making coverage decisions 

• Partner with Provider Engagement Team and Member Care teams to support care shopping and improve member experience 

• Contribute to quality improvement initiatives that enhance clinical review processes 

• Ensure adherence to clinical guidelines, internal policies, and regulatory requirements 

Role Requirements: 

• Bachelor's degree 

• Clinical credentials (RN) 

• 5+ years of experience as a nurse providing direct patient care, preferably in a hospital setting 

• 3+ years of utilization review experience, preferably in a health plan, managed care, or third-party administrator environment 

• Hands-on experience using Milliman Care Guidelines (MCG) 

• Experience in medical billing and/or coding in either: A.) Provider setting: billing, revenue cycle management, clinical auditing, legal compliance OR B.) Payor setting: utilization management, prior authorization review, payment integrity 

• Strong written communication skills, including drafting correspondence for members, patients, and providers 

• Demonstrated ability to think critically and make sound decisions with limited information 

• Proven cross-functional collaboration skills and experience presenting recommendations to leadership 

• Strong problem-solving ability, especially in managing escalated or complex cases 

• Prior authorization experience strongly preferred 

Sidecar Health adopts a market-based approach to compensation, where base pay varies depending on location and is further influenced by job-related skills and experience. The current expected salary range for this position is $82,500 - $95,000.