Clinical Review Nurse, RN

The Clinical Review Nurse (RN) supports the organization’s care management function by conducting clinical reviews, ensuring appropriate utilization of medical services, and maintaining compliance with regulatory and plan-specific guidelines. This role bridges clinical expertise with administrative processes to promote quality, cost-effective healthcare outcomes for members. This is a remote role open to candidates residing in Utah, Texas, or Arizona. HOW YOU’LL MAKE AN IMPACT:Clinical Review & Case Management Perform prospective, concurrent, and retrospective medical necessity reviews for inpatient, outpatient, and ancillary services. Apply evidence-based guidelines (e.g., MCG, Inter Qual) to determine medical necessity and appropriateness of care. Collaborate with physicians, providers, and other healthcare professionals regarding clinical determinations. Utilization Management Ensure timely processing of pre-certification, prior authorization, and concurrent review requests. Document clinical findings and review outcomes accurately within utilization management systems. Identify potential quality-of-care issues and escalate appropriately. Member Advocacy & Coordination Support case management teams in coordinating care for members with complex health needs. Assist in transitions of care to reduce unnecessary readmissions. Provide education to members and providers on coverage, benefits, and clinical guidelines. Compliance & Quality Ensure adherence to regulatory requirements (state, federal, ERISA) and accreditation standards (URAC, NCQA, etc.).Maintain confidentiality of Protected Health Information (PHI) in compliance with HIPAA.Participate in audits, quality improvement initiatives, and staff training.