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, ensure compliance with regulations, and collaborate with multidisciplinary teams to promote quality care.

Key responsibilities

• Assess services for members to ensure optimum outcomes and compliance with regulations
• Analyze clinical service requests against evidence-based guidelines and determine prior authorization
• 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
• Strong organizational and critical-thinking skills
• Proficiency in Microsoft Office and applicable software programs