Nurse - Clinical Review

Responsibilities:

• Perform utilization and clinical reviews to assess medical necessity and ensure policy compliance, facilitating case resolution.
• Collaborate with physicians, clients, and providers via phone and documentation to support the review process and appropriate care decisions.
• Adhere strictly to HIPAA, state, federal, URAC, and NCQA regulations while maintaining accurate written documentation.

Qualifications:

• Must be an RN or LPN/LVN graduate with an active, unrestricted U.S. license and minimum two years in utilization review or case management.
• Proficient in Microsoft Office, adaptable to healthcare software, with knowledge of NCD/LCD guidelines and insurance terminology.
• Possess excellent communication, critical thinking, and time management skills to work independently or as part of a team.

Additional Details:

• This is a full-time remote position based in the U.S., with a defined training and regular schedule in Central Standard Time.
• Compensation includes a base salary range and eligibility for performance-based bonuses, with a comprehensive benefits package provided.