State Licensed Care Review Clinician

Job Summary

A company is looking for a Care Review Clinician I.

Key Responsibilities

• Conduct prior authorization reviews and assess services for members to ensure compliance with regulations
• Analyze clinical service requests against evidence-based guidelines and identify appropriate benefits and eligibility
• Collaborate with multidisciplinary teams and maintain productivity and quality measures within the department

Required Qualifications

• At least 1 year of utilization management experience in a clinical setting
• Active, unrestricted State Nursing (RN, LVN, LPN) license in good standing
• Completion of an accredited Registered Nursing program or equivalent experience
• Minimum 0-2 years of clinical practice, preferably in hospital nursing, utilization management, or case management
• Experience with QNXT/UMK2/PEGA and knowledge of applicable state and federal regulations preferred