Care Review Clinician I/ UM

Job Title: Care Review Clinician I/ UM
Location: 100% Remote
Duration: 3 Months+ (Possible Extension)
 
Schedule: Mon - Fri (Standard shift timing)
 
Position Summary:

• Must reside in one of the following states to be considered: FL, GA, ID, IA, KY, MI, NE, NM, NY (outside greater-NYC), OH, TX, UT, WA (outside greater-Seattle), WI -- Ky Licensure ; UM experience preferred : For BH positions, may use Social Workers;
• The Utilization Review Nurse will work as part of the Utilization Management team, primarily responsible for inpatient medical necessity reviews, concurrent reviews, and prior authorization activities. The role ensures members receive the right care at the right time in the most appropriate setting, while maintaining compliance with state and federal regulations.

 
Key Responsibilities:

• Perform concurrent reviews and prior authorizations using medical necessity criteria (InterQual and related guidelines).
• Ensure accurate determinations of benefits, eligibility, and length of stay.
• Maintain daily productivity standards (15+ concurrent reviews/day or 20+ prior authorizations/day).
• Collaborate with interdisciplinary teams to promote continuity of care, including Behavioral Health and Long-Term Care.
• Escalate and present cases to Medical Directors as appropriate.
• Ensure compliance with NCQA, CMS, and state/federal guidelines.
• Accurately document and communicate determinations while maintaining HIPAA compliance.
• Support department goals, quality measures, and mentoring of new team members.

 
Qualifications:
Education: Graduate of an accredited Registered Nursing program (or equivalent experience/education).
 
Licensure: Active, unrestricted Nevada RN license (required upon hire or within 90 days).
 
Experience:

• 0–2 years of clinical nursing experience (hospital, utilization management, or case management preferred).
• Familiarity with InterQual criteria for medical necessity review.

 
Skills:

• Strong clinical assessment and critical thinking skills.
• Highly organized, with excellent attention to detail.
• Proficient with Microsoft Office Suite and comfortable working across multiple systems/screens.
• Strong written and verbal communication skills.
• Ability to work independently in a fast-paced environment while meeting productivity and compliance standards.