Clinical Review Nurse

Job Title: Clinical Review Nurse – Utilization Management Location: Remote Job Type: Full-Time About the Role: We are seeking an experienced Clinical Review Nurse – Utilization Management to join our team. In this role, you will conduct clinical reviews to assess the appropriateness, medical necessity, and efficiency of healthcare services. You will collaborate with providers, members, and multidisciplinary teams to ensure high-quality care delivery while maintaining cost-effective utilization. Key Responsibilities: • Perform utilization management reviews, including pre-authorization, concurrent, and retrospective reviews, using evidence-based criteria. • Evaluate medical records, treatment plans, and clinical documentation to determine medical necessity and compliance with health plan policies. • Provide education and guidance to providers and members regarding utilization management decisions and healthcare benefits. • Collaborate with healthcare providers to ensure timely and appropriate care delivery. • Identify gaps in care and recommend alternative treatment plans when necessary. • Document all reviews, decisions, and communications accurately in electronic health records (EHR). • Stay current with industry regulations, accreditation standards, and clinical guidelines. Qualifications: • Active Registered Nurse (RN) license in good standing. • 2+ years of experience in utilization management, case management, or a related clinical role. • Strong knowledge of utilization management principles, medical necessity criteria (e.g., InterQual, Milliman), and health insurance regulations. • Excellent critical thinking, communication, and organizational skills. • Proficiency in electronic medical records (EMR) systems and Microsoft Office. Preferred Qualifications: • Bachelor of Science in Nursing (BSN) or equivalent degree. • Certification in Utilization Review (UR) or Case Management (CCM). • Experience with Medicare, Medicaid, or commercial insurance plans. • Bilingual (Spanish or other languages). Work Environment: • Fully remote position with flexible hours. • Must have reliable internet access and a private workspace. • Collaboration with a dynamic and supportive team in a virtual environment. Why Join Us? • Competitive salary and comprehensive benefits package. • Opportunity to make a meaningful impact by ensuring members receive appropriate and efficient care. • Professional development and career advancement opportunities. • Supportive team culture in a growing organization. How to Apply: Submit your resume detailing your experience in utilization management and clinical review. Join us in shaping the future of healthcare! Job Types: Full-time, Contract Pay: $35.08 - $42.37 per hour Expected hours: No less than 40 per week Benefits: • Flexible schedule • Health insurance • Paid time off Schedule: • 8 hour shift • Day shift Experience: • Utilization review: 4 years (Required) License/Certification: • RN License of Texas State (Required) Location: • Texas (Required) Work Location: Remote Apply Job!