New York Licensed Clinical Review Nurse

Job Summary

Analyzing prior authorization requests for medical necessity, the full-time New York Licensed Clinical Review Nurse will work remotely, conducting clinical reviews and collaborating with healthcare providers to ensure timely and appropriate care for members during Eastern Time hours.

Key responsibilities

• Perform medical necessity and clinical reviews of authorization requests in accordance with regulatory guidelines
• Coordinate with healthcare providers and interdepartmental teams to assess and expedite authorization requests
• Document and maintain member clinical information to ensure compliance with regulatory standards

Required qualifications

• Active and unrestricted New York State Registered Nurse (RN) licensure
• Degree from an Accredited School of Nursing or Bachelor's degree in Nursing
• 2 - 4 years of related experience in clinical review or utilization management
• Knowledge of Medicare and Medicaid regulations preferred
• Experience with utilization management processes preferred