New York Licensed Clinical Review Nurse

Job Summary

Routinely reviewing complex prior authorization requests, the full-time New York Licensed Clinical Review Nurse will determine medical necessity and appropriate levels of care while collaborating with healthcare providers and managing service authorizations in a remote setting.

Key responsibilities

• Conducts medical necessity and clinical reviews of authorization requests in accordance with regulatory guidelines
• Collaborates with healthcare providers and authorization teams to ensure timely reviews and member care
• Manages service authorization requests related to member transfers or discharges to facilitate timely care transitions

Required qualifications

• Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing
• 4 - 6 years of related experience in clinical review or utilization management
• Advanced clinical knowledge with the ability to analyze authorization requests
• Strong knowledge of Medicare and Medicaid regulations
• Current New York State licensure as a Registered Nurse, Occupational Therapist, or Physical Therapist