North Carolina Licensed Review Nurse

Job Summary

To support high-quality care decisions, the full-time Remote Utilization Management/Review Nurse will review and evaluate member cases for medical necessity, ensuring compliance with healthcare service utilization while collaborating with providers and internal teams.

Key Responsibilities

• Review and evaluate assigned member cases for medical necessity using established guidelines
• Communicate and collaborate with internal teams and external partners to document review outcomes
• Determine cases requiring escalation for secondary review and coordinate peer-to-peer reviews as needed

Required Qualifications

• Active RN license with at least 3 years of clinical experience, or active LPN license with at least 5 years of clinical experience
• Valid and unrestricted clinical license in North Carolina or compact multistate licensure
• Experience in utilization review, managed care, or medical necessity review is preferred
• Strong analytical and documentation skills
• Ability to work independently while collaborating within a team environment