Care Review Clinician, Inpatient Review (RN) - Remote

Overview

The Care Review Clinician is responsible for assessing, facilitating, planning, and coordinating integrated delivery of care for members with high need potential, ensuring quality care that is both medically appropriate and cost-effective.

In Short

• Assesses inpatient services for optimum outcomes and compliance.
• Analyzes clinical service requests against evidence-based guidelines.
• Identifies benefits, eligibility, and expected length of stay for treatments.
• Conducts inpatient reviews for financial responsibility.
• Processes requests within required timelines.
• Refers cases to Medical Directors efficiently.
• Requests additional information from members or providers.
• Collaborates with multidisciplinary teams.
• Adheres to Utilization Management policies.
• Occasional travel may be required.

Requirements

• Graduate from an Accredited School of Nursing.
• 3+ years hospital acute care/medical experience.
• Active, unrestricted State Registered Nursing (RN) license.
• Valid driver's license with a good driving record.
• Preferred: Bachelor's Degree in Nursing.
• Preferred: Recent hospital experience in ICU, Medical, or ER unit.
• Preferred: Active, unrestricted Utilization Management Certification (CPHM).

Benefits

• Competitive benefits and compensation package.
• Equal Opportunity Employer (EOE).