Registered Nurse Clinical Reviewer

Job Summary

Managing medical necessity reviews, the full-time Remote Registered Nurse Clinical Reviewer will process authorizations for healthcare services, assist with discharge planning, and coordinate care for members while ensuring compliance with regulations.

Key responsibilities:

• Complete prospective, concurrent, and retrospective reviews for various healthcare services
• Identify and coordinate care transitions, engaging with collaborative care partners
• Maintain knowledge of regulations and assist with quality improvement and care management referrals

Required qualifications:

• Associates of Science (A.S) from an accredited registered nursing (RN) program
• Three (3) years of clinical experience required
• Preferred experience in med/surgical, emergency acute care, or home health
• Utilization Management/Utilization Review experience preferred
• Current, unrestricted Registered Nurse (RN) Licensure in the state(s) of practice required