New York Licensed Clinical Review Nurse

Job Summary

Analyzing prior authorization requests, the full-time New York Licensed Clinical Review Nurse will determine medical necessity and appropriate levels of care while working remotely during Eastern Time hours.

Key responsibilities

• Perform medical necessity and clinical reviews of authorization requests in accordance with regulatory guidelines
• Collaborate with healthcare providers and authorization teams to ensure timely reviews and appropriate care for members
• Document and maintain member clinical information in health management systems to ensure compliance with regulations

Required qualifications

• Active and unrestricted New York State Registered Nurse (RN) licensure strongly preferred
• Graduate 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
• Familiarity with utilization management processes preferred