Nurse Reviewer, Registered Nurse

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

📋 Description

• Assess and analyze medical records to establish the necessity and appropriateness of care.

• Achieve quality and productivity benchmarks.

• Accurately document review outcomes and the underlying rationale in a timely manner.

• Make approval decisions or escalate cases to physician consultants and process their recommendations.

• Conduct prior authorization, precertification, and retrospective evaluations.

• Draft decision letters as necessary.

• Provide training, mentorship, and support to new Nurse Reviewers.

• Uphold RN licensure and remain informed about clinical criteria, policies, and regulations.

• Gain proficiency in various claim types through cross-training.

• Suggest process enhancements and technological solutions to improve quality, productivity, and client satisfaction.

⛳️ Requirements

• Strong computer and typing skills.

• Familiarity with Microsoft Windows, Outlook, Excel, Word, PowerPoint, and web browsers.

• An active, unrestricted RN license in the United States and in the primary state of residence.

• An active compact multistate unrestricted RN license as outlined by the Nurse Licensure Compact (NLC).

• At least 5 years of clinical experience in an inpatient hospital environment.

• A minimum of 2 years of experience in utilization review or claims auditing.

• Experience with Milliman or InterQual criteria.

• Availability to work standard business hours.

• Ability to effectively collaborate with cross-functional teams and departments.

• Willingness to work extended hours as necessary to meet business needs.

🏝️ Benefits

• Flexible hours.

• Work-life balance.

• Opportunities for continuous learning and career advancement.

• Immediate eligibility for medical, dental, vision, and paid time off benefits.

• Educational assistance.

• Access to leadership and technical development academies.

• Flexible vacation policy.

• 401(k) employer matching.

• Comprehensive health benefits.

• Travel requirement of 0–10%.