No onsite requirements anticipated during the assignment.
Position Overview
We are seeking a Registered Nurse Review Analyst to support inpatient precertification and utilization management activities in a fully remote environment.
This role is responsible for performing prospective, concurrent, and retrospective medical reviews to determine medical necessity, appropriate level of care, intensity of service, and length of stay for healthcare services.
The ideal candidate will have a strong clinical background, experience evaluating patient care needs, and the ability to collaborate with providers, facilities, and members to support quality healthcare outcomes.
Responsibilities
Perform prospective, concurrent, and retrospective reviews of inpatient, outpatient, ambulatory, and ancillary healthcare services.
Evaluate medical necessity, level of care, intensity of service, and appropriate length of stay.
Review and assess appeal requests submitted by providers, facilities, and members.
Apply clinical knowledge and evidence-based guidelines to utilization review decisions.
Establish care plans and coordinate care across the healthcare continuum when appropriate.
Conduct member outreach and assessments to support care coordination initiatives.
Collaborate with physicians, healthcare providers, and interdisciplinary teams to facilitate quality patient care.
Maintain accurate documentation and comply with organizational policies, regulatory requirements, and utilization management standards.