Care Review Clinician II (RN or LVN) - Remote

Overview

A leading Managed Care Organization is seeking an experienced and detail-oriented Care Review Clinician II (RN or LVN) to join their Utilization Management team. This remote position plays a key role in reviewing clinical service requests, supporting continuity of care, and ensuring appropriate, cost-effective healthcare decisions are made in compliance with regulatory and clinical guidelines.

In Short

• Perform clinical reviews of service requests including concurrent and prior authorization determinations
• Serve as clinical support to the Continuity of Care (COC) and Community Support teams
• Determine whether requests meet COC or community support criteria
• Conduct provider outreach as appropriate to support authorizations and care coordination
• Utilize InterQual and other clinical guidelines to assess medical necessity
• Ensure documentation meets compliance, quality, and turnaround standards
• Create and manage authorizations in accordance with established UM processes
• Participate in team meetings and collaborate with other departments

Requirements

• Active, unrestricted LVN or RN license in California
• 3–5 years of clinical experience (inpatient, outpatient, or hospital setting preferred)
• Prior experience in Utilization Management, Concurrent Review, or Prior Authorization
• Strong analytical and critical thinking skills in a fast-paced, metric-driven environment
• Solid computer proficiency, including ability to toggle between multiple databases and tools
• Experience using InterQual or similar medical necessity criteria tools
• Knowledge of HIPAA and regulatory compliance standards
• Excellent verbal and written communication skills

Benefits

• Must provide your own secure and quiet workspace for remote work
• Equipment (laptop, monitors, etc.) will be provided by the organization
• Must be available to work 8-hour shifts during PST business hours, Monday–Friday