Nevada Licensed Clinical Care Reviewer

Job Summary

Working full-time in a remote capacity, the Nevada Licensed Clinical Care Reviewer will process medical necessity reviews, assist with discharge planning, and coordinate care for members while ensuring compliance with healthcare regulations.

Key responsibilities

• Complete prospective, concurrent, and retrospective reviews for various healthcare services and procedures
• Coordinate care by engaging with collaborative care partners and medical directors as needed
• Identify quality issues and refer members for Care Management while providing guidance to clinical and non-clinical staff

Required qualifications

• Current, unrestricted Registered Nurse (RN) Licensure in Nevada
• Completion of an accredited registered nursing (RN) degree program (Associates of Science required)
• Three (3) years of clinical experience, preferably in med/surgical, emergency acute care, or home health
• Experience in Utilization Management/Utilization Review preferred
• Knowledge of Medicaid, Medicare, or Commercial insurance practices preferred