Independent Review Nurse Manager

Join Provider Resources (PRI) and Make an Impact in Healthcare! At PRI, we’re passionate about driving integrity and advancing quality across the healthcare system. As a trusted leader in the industry, we’re tackling some of healthcare’s biggest challenges—improving compliance, advancing health equity, and enhancing quality and clinical outcomes while helping organizations improve care delivery and create meaningful change. We believe that people are at the heart of healthcare, and focus on scalable, person-centered strategies that prioritize clinical excellence and evidence-based practices. Our work supports a broad network of stakeholders, including providers, patients, caregivers, payers, and regulators. We strive to enhance experiences, improve outcomes, and foster a healthier future for all. If you’re looking to be part of a forward-thinking team that makes a difference, PRI is the place for you!

The Independent Review Nurse Manager is a key leadership role responsible for the day-to-day management of clinical independent review operations and the strategic growth of the Independent Review Organization (IRO) contracts within PRI. This position will report to the VP of Health Care Quality & Strategic Solutions and will initially be responsible for reviewing and management of IRO cases. As the program grows, the Manager will build and lead a team of clinical reviewers, ensuring all review activities are conducted with the highest level of impartiality, quality, and compliance with federal and state regulations, as well as with URAC and other accreditation standards. The Manager will build efficient processes, track key metrics, and drive high-quality outcomes.

Leadership and Management: Build, mentor, and manage a team of independent review nurses and other staff, including hiring, training, and performance evaluations as the program grows. Assign and prioritize case reviews to the expert clinical panel as well as staff, ensuring all regulatory and client-specific timeframes are met. Complete quality assurance (QA) reviews of case files to ensure accuracy, consistency, and compliance. Interact directly with internal and external stakeholders, including clients, regulators, and accreditation bodies. Operational and Clinical Responsibilities: Conduct independent clinical reviews of medical records, appeals, and prior authorization requests to determine medical necessity and appropriateness of care. Apply evidence-based guidelines, clinical criteria (e.g., MCG, InterQual), and regulatory standards to all reviews. Prepare clear, concise, and defensible written summaries and recommendations for each case reviewed. Collaborate with physician reviewers and other clinical staff to ensure a comprehensive and consistent review process. Maintain a current, unrestricted RN license. Stay current on clinical guidelines, regulatory changes, and payer requirements related to internal and external review processes. Participate in audits, training, and continuous quality improvement initiatives. Strategic Development: Partner with leadership to develop and execute strategies for growing the IRO and expanding services. Build and refine operational processes to improve efficiency, accuracy, and scalability. Track, analyze, and report on key performance indicators (KPIs) to monitor IRO outcomes and results. Ensure all IRO activities and processes adhere to URAC standards and all applicable federal and state laws.