Registered Nurse Care Reviewer

Job Summary

To support clinical member services, the full-time Registered Nurse Care Reviewer will assess service requests to ensure medical necessity, compliance with guidelines, and optimal member outcomes while collaborating with multidisciplinary teams.

Key responsibilities

• Assess services for members to ensure compliance with state and federal regulations
• Analyze clinical service requests against evidence-based clinical guidelines
• Conduct reviews for prior authorization and financial responsibility determinations

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