RN Utilization Review Clinician

Job Summary

Working remotely on a full-time basis, the RN Utilization Review Clinician will assess clinical service requests to ensure medical necessity, compliance with guidelines, and optimal member outcomes, with a requirement to work on Saturdays.

Key responsibilities

• Assess services for members to ensure compliance with state and federal regulations and guidelines
• Analyze clinical service requests against evidence-based clinical guidelines and determine prior authorization needs
• Collaborate with multidisciplinary teams to promote effective care delivery and make appropriate referrals to clinical programs

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
• Proficiency in Microsoft Office and applicable software programs
• Ability to prioritize and manage multiple deadlines effectively
• Strong organizational, problem-solving, and critical-thinking skills