Texas Licensed Clinical Review Nurse

Job Summary

Analyzing prior authorization requests for medical necessity, the full-time Texas Licensed Clinical Review Nurse will work remotely to ensure appropriate levels of care in accordance with national standards and member benefit coverage.

Key responsibilities

• Perform medical necessity and clinical reviews of authorization requests to determine appropriateness of care
• Collaborate with healthcare providers and the authorization team to ensure timely review of services for members
• Document and maintain all member clinical information in health management systems to ensure regulatory compliance

Required qualifications

• Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing
• 2 - 4 years of related experience in clinical review or utilization management
• Texas RN license required
• Knowledge of Medicare and Medicaid regulations preferred
• Experience analyzing authorization requests for medical necessity preferred