Utilization Review Nurse

Job Title: Clinical Care Reviewer-Utilization Management- Non-Member Facing Location: FULLY REMOTE Duration: 3 months (possibility of getting an extension) Shift: 8 AM to 5:30 PM, with flexibility for evenings, holidays, occasional overtime, and weekends based on business needs

Under the direction of a supervisor, the Clinical Care Reviewer – Utilization Management evaluates medical necessity for inpatient and outpatient services, ensuring treatment aligns with clinical guidelines, regulatory requirements, and patient needs. This role requires reviewing provider requests, gathering necessary medical documentation, and making determinations based on clinical criteria. Using professional judgment, the Clinical Care Reviewer assesses the appropriateness of services, identifies care coordination opportunities, and ensures compliance with medical policies. When necessary, cases are escalated to the Medical Director for further review. The reviewer independently applies medical and behavioral health guidelines to authorize services, ensuring they meet the patient’s needs in the least restrictive and most effective manner. The Clinical Care Reviewer must maintain a strong working knowledge of federal, state, and organizational regulations and consistently apply them in decision-making. Productivity expectations include meeting established turnaround times, quality benchmarks, and efficiency metrics in a fast-paced environment. The Clinical Care Reviewer – Utilization Management will also be counted upon to: Conduct utilization management reviews by assessing medical necessity, appropriateness of care, and adherence to clinical guidelines. 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. Communicate determinations effectively, providing clear, evidence-based rationales for approval or denial decisions. Identify and escalate complex cases requiring physician review or additional intervention. Ensure compliance with industry standards, including Medicare, Medicaid, and private payer requirements. Maintain productivity and efficiency by meeting established performance metrics, turnaround times, and quality standards in a high-volume environment