State Licensed Clinical Care Reviewer

Job Summary

A company is looking for a Clinical Care Reviewer in Utilization Management.

Key Responsibilities

• Evaluate medical necessity for inpatient and outpatient services, ensuring alignment with clinical guidelines and patient needs
• Collaborate with healthcare providers to facilitate timely authorizations and optimize patient care
• Analyze medical records and clinical data to ensure compliance with regulatory and payer guidelines

Required Qualifications, Training, and Education

• Associate's Degree in Nursing (ASN) required; Bachelor's Degree in Nursing (BSN) preferred
• An active compact state Registered Nurse (RN) license in good standing is required
• 3+ years of diverse clinical experience in relevant healthcare settings
• Proficiency in Electronic Medical Record Systems
• Strong understanding of utilization review processes and regulatory compliance