Registered Nurse Care Reviewer

Job Summary

To support clinical member services, the full-time Registered Nurse Care Reviewer will assess service requests for medical necessity, ensuring compliance with clinical guidelines and regulations while collaborating with multidisciplinary teams to promote quality member care.

Key responsibilities

• Assess services for members to ensure optimum outcomes and compliance with state/federal regulations
• Analyze clinical service requests against evidence-based clinical guidelines and determine prior authorization needs
• Collaborate with medical directors and multidisciplinary teams to facilitate integrated care delivery

Required qualifications

• At least 2 years of experience in hospital acute care, inpatient review, or managed care
• Active and unrestricted Registered Nurse (RN) license in the state of practice
• Ability to prioritize and manage multiple deadlines effectively
• Proficiency in Microsoft Office suite and applicable software programs
• Strong organizational and critical-thinking skills