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 during Eastern Time hours, providing recommendations to medical teams and ensuring timely reviews of services.

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 ensure timely care for members
• Document and maintain member clinical information in health management systems to ensure regulatory compliance

Required qualifications

• Active and unrestricted New York State Registered Nurse (RN) licensure
• 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
• Understanding of utilization management processes preferred