Texas Licensed Clinical Review Nurse

Job Summary

Analyzing prior authorization requests, the full-time Texas Licensed Clinical Review Nurse will determine medical necessity and appropriate levels of care, working remotely to ensure timely and compliant service delivery.

Key responsibilities

• Perform medical necessity and clinical reviews of authorization requests in accordance with regulatory guidelines
• Collaborate with healthcare providers and the authorization team to ensure timely review and authorization of services
• Document and maintain member clinical information in health management systems to ensure compliance with regulations

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
• Clinical knowledge to analyze authorization requests and determine medical necessity preferred
• Familiarity with Medicare and Medicaid regulations preferred