California Licensed Care Review RN

Job Summary

To support clinical member services, the full-time California Licensed Care Review RN will verify the medical necessity of services, analyze clinical service requests, and ensure compliance with guidelines while working in the Pacific Standard Time (PST) zone.

Key responsibilities

• Assess services for members to ensure optimum outcomes and compliance with regulations
• Analyze clinical service requests against evidence-based clinical guidelines
• Conduct reviews to determine prior authorization and financial responsibility for treatments

Required qualifications

• At least 2 years of experience in hospital acute care, inpatient review, or managed care
• Active and unrestricted Registered Nurse (RN) license in the state of practice
• Ability to prioritize and manage multiple deadlines effectively
• Proficiency in Microsoft Office suite and applicable software programs
• Strong organizational and critical-thinking skills