Registered Nurse Care Reviewer

Job Summary

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

Key responsibilities

• Assesses services for members to ensure optimum outcomes and compliance with regulations
• Analyzes clinical service requests against evidence-based clinical guidelines
• Conducts reviews to determine prior authorization and financial responsibility for treatments

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