New York State Licensed Clinical Review Nurse

Job Summary

To support the Medical Management/Health Services team, the full-time New York State Licensed Clinical Review Nurse will perform concurrent reviews to evaluate member health, assess the appropriateness of care, and contribute to discharge planning in a fully remote capacity.

Key responsibilities

• Conducts concurrent reviews to determine overall health and appropriate level of care for members
• Collaborates with healthcare providers and Medical Affairs to validate medical necessity and approve care determinations
• Documents findings and discharge plans in health management systems according to utilization management policies

Required qualifications

• Active New York State RN licensure is required
• Graduation from an accredited school of nursing or a Bachelor's degree in Nursing (BSN)
• 2-4 years of related nursing experience, including a minimum of 2 years in acute care
• Knowledge of Medicare and Medicaid regulations is preferred
• Familiarity with utilization management processes is preferred