Care Review Clinician I – RN Inpatient Medical

Job Title: Care Review Clinician I – RN Inpatient Medical
Location: Chicago Remote (IL)
Duration: 3+ Months (Possible Extension)
 
Pay Rate: $37.97/hr. on W2

Time Zones: Must be able to work within CST or EST
Schedule: Variable hours Sunday–Sunday, potential to work until 6 PM CST
Equipment: Dual monitors & docking station required
 
Job Summary:
The Care Review Clinician collaborates with members, providers, and multidisciplinary teams to assess, facilitate, plan, and coordinate integrated care across the continuum. Focuses on medical-surgical adult and pediatric inpatient members to ensure medically appropriate, cost-effective care aligned with clinical guidelines.
 
Key Responsibilities:

• Assess inpatient services for optimal clinical and financial outcomes, ensuring compliance with state and federal regulations.
• Analyze clinical service requests from members and providers using evidence-based guidelines.
• Determine appropriate benefits, eligibility, and expected length of stay for requested treatments/procedures.
• Conduct inpatient reviews to determine financial responsibility for the organization and members; may perform prior authorization reviews.
• Escalate complex cases to Medical Directors efficiently and request additional information as needed.
• Collaborate with multidisciplinary teams, including Case Management, to ensure member needs are addressed.
• Adhere to Utilization Management (UM) policies and procedures, including maintaining HIPAA compliance.
• Maintain timely documentation of clinical reviews and authorizations using multiple applications and dual monitors.

 
Required Qualifications:

• Education: Completion of an accredited Registered Nurse (RN) program.
• Licensure: Active, unrestricted IL State RN license in good standing.
• Experience:
  • 1–3 years Medical/Surgical acute hospital care experience.
  • 1+ year Utilization Management (UM) experience.
• Skills:
  • Knowledge of inpatient medical necessity and UM processes.
  • Flexibility, dependability, and reliability.
  • Strong time management and organizational skills.
  • Attention to detail, especially for HIPAA compliance.
  • Ability to multi-task in a fast-paced environment.
  • Proficiency in Microsoft Office and ability to work with multiple applications/monitors.
• Preferred: Familiarity with medical necessity criteria (e.g., MCG guidelines) and MCO/UM experience.

 
Day-to-Day Activities:

• Review clinical submissions from facilities for Client members admitted for inpatient medical care.
• Ensure authorization, clinical, and discharge information is up to date and received timely.
• Refer cases requiring medical necessity review to Medical Directors.
• Collaborate with Case Management and other multidisciplinary team members.
• Attend weekly team meetings and monthly 1:1 sessions with supervisors.