Registered Nurse Clinical Reviewer

Job Summary

Working remotely on a full-time basis, the Registered Nurse Clinical Reviewer will process medical necessity reviews 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 of various healthcare services, including inpatient and outpatient procedures
• Identify and coordinate care transitions, engaging with care partners and medical directors as necessary
• Monitor healthcare service delivery and refer quality issues to Quality Improvement and appropriate members for Care Management

Required qualifications:

• Associate of Science (A.S) from an accredited registered nursing (RN) degree program
• Three (3) years of clinical experience required, with a preference for med/surgical, emergency acute care, or home health experience
• Utilization Management/Utilization Review experience preferred
• Current, unrestricted Registered Nurse (RN) Licensure in state(s) of practice required
• MCG Certification or the ability to obtain it within six (6) months of hire required