Clinical Review Nurse, RN

This is a fully remote position, open to applicants in Utah.

📋 Description

• Conduct prospective, concurrent, and retrospective reviews of medical necessity for inpatient, outpatient, and ancillary services.

• Utilize evidence-based guidelines (e.g., MCG, InterQual) to assess medical necessity and the appropriateness of care.

• Work collaboratively with physicians, providers, and other healthcare professionals to make clinical determinations.

• Ensure the timely processing of pre-certification, prior authorization, and concurrent review requests.

• Accurately document clinical findings and review outcomes within utilization management systems.

• Identify and escalate potential quality-of-care issues as necessary.

• Assist case management teams in coordinating care for members with complex health needs.

• Support transitions of care to minimize unnecessary readmissions.

• Educate members and providers on coverage, benefits, and clinical guidelines.

• Ensure compliance with regulatory requirements (state, federal, ERISA) and accreditation standards (URAC, NCQA, etc.).

• Engage in audits, quality improvement initiatives, and staff training.

⛳️ Requirements

• A current, unrestricted Registered Nurse (RN) license for Utah or a compact license.

• At least 3+ years of clinical experience (acute care, utilization review, or case management preferred).

• Previous experience in Utilization Management within a TPA or health plan setting is highly desired.

• Knowledge of medical necessity criteria (MCG, InterQual) is preferred.

• Familiarity with ERISA, DOL, and state/federal regulations governing TPA operations is an advantage.

• Strong clinical assessment, critical thinking, and decision-making abilities.

• Excellent written and verbal communication skills.

• Proficient in EMR/UM software and Microsoft Office Suite.

• Maintain confidentiality of Protected Health Information (PHI) in accordance with HIPAA regulations.

🏝️ Benefits

• 5% annual bonus based on company profitability.

• Affordable health, vision, and dental insurance for you and your family.

• The company contributes up to $2,300 to your Health Savings Account annually.

• Wellness program that offers additional contributions toward your HSA.

• Automatic 3% contribution to the retirement plan.

• Opportunities for career development and growth.

• 15 days of paid time off and 10 paid holidays each year.