California Licensed Clinical Review Nurse

Job Summary

A company is looking for a Utilization Review Nurse focused on appeals, grievances, medical necessity review, and utilization management.

Key Responsibilities

• Conduct clinical reviews of appeals, grievances, and disputed cases involving medical necessity and level of care
• Review various medical records and apply clinical guidelines, policies, and procedures
• Document clinical findings and generate written correspondence for providers and regulatory entities

Required Qualifications

• Active, unrestricted California RN license
• Minimum 3 years of acute care clinical experience
• Minimum 2 years of appeals and grievances casework
• Experience with medical necessity review and prior authorization
• Working knowledge of InterQual, MCG, and managed care regulations