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Job Requirements of Care Review Clinician III:
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Employment Type:
Contractor
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Location:
Spokane, WA (Onsite)
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Care Review Clinician III
Job Title: Care Review Clinician III (NICU/Pediatrics)
Location: Fully Remote
Schedule: Part-Time (20 hours per week)
Working Hours: Between 8:00 AM – 5:00 PM PST (Flexible days; daily coverage preferred)
Preferred Location: Washington (WA) preferred, but candidates must be able to work PST hours
AZ, FL, GA, ID, IA, KY, MI, MS, NE, NM, NY (outside greater-NYC), OH, SC, TX, UT, WA (outside greater-Seattle), WI
Position Summary
We are seeking a dedicated Registered Nurse (RN) to join the Utilization Management team in a part-time, fully remote role.
In this role, the nurse will review NICU or Pediatric inpatient cases for medical necessity using MCG guidelines to ensure members receive the right care at the right place and time.
The position involves concurrent review, prior authorization, and utilization review activities to ensure optimal outcomes, cost effectiveness, and compliance with state and federal regulations.
Key Responsibilities
- Perform inpatient utilization review to determine medical necessity for NICU or Pediatric cases using MCG criteria.
- Conduct concurrent reviews and prior authorizations according to client policies.
- Review hospitalizations and procedures to ensure appropriate level of care and length of stay.
- Evaluate member eligibility, benefits, and clinical documentation.
- Collaborate with internal departments to support continuity of care, including Behavioral Health and Long-Term Care teams.
- Refer cases to Medical Directors when appropriate.
- Maintain productivity and quality metrics within the Utilization Management department.
- Participate in team meetings and support onboarding or mentoring of new team members as needed.
- Maintain professional relationships with providers, internal teams, and members.
- Ensure compliance with HIPAA, state, and federal healthcare regulations.
Required Qualifications
- Active, unrestricted RN license in good standing.
- Completion of an accredited Registered Nursing program.
- 5–7 years of clinical nursing experience.
- Strong experience in NICU or Pediatric nursing.
- Experience reviewing cases for medical necessity using MCG or InterQual guidelines.
- Experience with Utilization Review, Case Management, or Hospital Nursing.
Preferred Qualifications
- Previous experience in Utilization Management or Case Management.
- Familiarity with NCQA standards.
- Experience with concurrent review and prior authorization processes.
- Knowledge of state and federal healthcare regulations.
Key Skills
- Strong organization and time management skills
- In-depth NICU knowledge and leveling experience
- Ability to manage multiple cases and priorities
- Excellent communication and problem-solving skills
- Proficiency with Microsoft Office
- Ability to work independently in a remote environment