Nurse - Clinical Review
Core
Performs utilization review of healthcare cases to determine medical necessity and ensure compliance with client policies and regulatory standards.
Role type
Utilization Review Nurse (Clinical Review)
Builds
Clinical review decisions and documentation for insurance claims and care authorization
Domain
Healthcare / Insurance Utilization Management
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Utilization review, case management, clinical quality improvement, regulatory compliance, HIPAA adherence, critical thinking, time management
Preferred skills
Knowledge of NCD/LCD, insurance terminology, state/federal regulatory standards
Technologies
Microsoft Office, healthcare-specific software systems
Responsibilities
Perform utilization review to determine medical necessity, facilitate resolution of escalated cases, collaborate with client personnel to resolve concerns, refer quality issues to leadership, maintain written documentation, adhere to URAC & NCQA standards, engage with providers via phone to facilitate review process
Seniority
Mid-level, hands-on IC