Clinical Reviewer

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

📋 Description

• Evaluate the medical necessity and quality of healthcare services through utilization management assessments.

• Perform prospective, concurrent, and retrospective utilization management evaluations.

• Utilize clinical review criteria, organizational policies, guidelines, and screening tools (InterQual).

• Consult with physician/practitioner advisors when services fail to meet medical necessity standards.

• Collaborate with internal teams and escalate cases for further review when necessary.

• Forward cases to management when needed.

• Offer subject matter expertise in clinical and utilization review processes.

• Address inquiries from providers, customers, and stakeholders regarding determinations and procedures.

• Reach out to providers, case managers, consultants, and community support coordinators to gather additional clinical information.

• Ensure accurate documentation and adherence to all regulatory and contractual standards.

⛳️ Requirements

• BA/BS in Nursing.

• An equivalent combination of education and/or relevant experience may be accepted based on contract specifications.

• At least 3 years of direct patient care (clinical) experience.

• Current, active, unrestricted RN license.

• Must fulfill New Mexico state and contract-specific requirements.

• Familiarity with InterQual Criteria.

• High proficiency in Microsoft Office Suite and knowledge of database systems.

🏝️ Benefits

• Medical, dental, and vision insurance.

• Paid time off for vacation, illness, and volunteer activities.

• Retirement savings plan with employer contributions.

• Financial assistance for adoption.

• Paid parental leave.

• And much more!