Fully Remote - Care Review Clinician I

Job Title: Care Review Clinician I
Shift: Tuesday – Saturday, 8 AM – 5 PM EST
Location: 100% Remote (Candidates must reside in one of the following states:AZ, FL, GA, ID, IA, KY, MI, NE, NM, NY (outside greater NYC), OH, TX, UT, WA (outside greater Seattle), WI)
Pay Rate : $42.01

Role Overview:
The Utilization Management Nurse will be responsible for reviewing provider submissions for prior service authorizations and determining medical necessity. The role ensures members receive appropriate care while maintaining compliance with state and federal regulations.
This role is ideal for professionals with a background in behavioral health services and/or managed care organizations (MCOs) specializing in utilization management.

Key Responsibilities:
Conduct concurrent reviews and prior authorizations for inpatient services.
Evaluate medical necessity and length of stay using InterQual and other clinical guidelines.
Collaborate with interdepartmental teams, including Behavioral Health and Long-Term Care, to ensure continuity of care.
Maintain productivity and quality standards, participating in regular staff meetings.
Support new team members through mentoring.
Communicate with medical directors as needed for case consultations.
Ensure compliance with workplace safety standards and company policies.

Qualifications & Skills:
Education:
Completion of an accredited Registered Nursing program (equivalent experience and education may be considered).

Experience:
0-2 years of clinical practice (preferably in hospital nursing, utilization management, or case management).

Licensure: Active, unrestricted State Nursing license (RN, LPN, LCSW or LPC- in any state) in good standing.

Skills:
Strong problem-solving and communication skills.
Ability to work independently and manage multiple priorities.
Knowledge of NCQA, state, and federal regulations.
Proficiency in Microsoft Office.
Understanding of HIPAA compliance.
Experience with InterQual for medical necessity determinations.