State Licensed RN Reviewer

Job Summary

A company is looking for an RN Reviewer.

Key Responsibilities

• Perform medical necessity reviews including inpatient, concurrent, prior authorization, and retrospective reviews
• Consult with Medical Directors on cases that do not meet applicable criteria or medical policies
• Document clinical information accurately and maintain compliance with accreditation and regulatory requirements

Required Qualifications

• Registered Nurse with an active, unencumbered license in the state of residence
• Minimum of 3 years of clinical experience, with required Utilization Management experience
• Experience in acute care and/or post-acute care environments
• Preferred Bachelor's degree in Nursing, Business, or equivalent professional work experience
• Proficient user of MCG guidelines and familiarity with NCQA and CMS standards