Registered Nurse Clinical Reviewer

Job Summary

A company is looking for a Clinical Reviewer, Nurse to evaluate cases and support utilization management.

Key Responsibilities

• Evaluate cases that do not pass the authorization approval process and render decisions based on clinical criteria
• Review clinical records to approve services that meet established criteria and monitor quality of care standards
• Document communications with medical staff regarding approvals and denials while ensuring compliance with required timeframes

Required Qualifications

• Current, unrestricted state licensure as a Registered Nurse
• Associate or Bachelor's degree in nursing
• 5+ years of clinical experience preferred
• No history of disciplinary or legal action by a state medical board
• Must not be under exclusion or sanction by any state or federal health care program