RN Reviewer
Core
Perform prospective, concurrent, and retrospective reviews to determine the medical appropriateness of clinical requests for inpatient admissions, outpatient services, and procedures across Commercial, Medicare, and Medicaid lines of business.
Role type
Utilization Review Nurse (RN)
Builds
Cost-effective care decisions and utilization management protocols
Domain
Healthcare / Utilization Management
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Clinical judgment, critical thinking, knowledge of utilization and case management programs, proficiency with MCG (CareWebQI), ability to apply coverage guidelines
Preferred skills
HEDIS abstraction, Legal RN, Utilization Review background
Technologies
MCG (CareWebQI), Google Workspace, Zoom
Responsibilities
Review medical necessity for inpatient, concurrent, prior auth, and retrospective cases; Collaborate with Medical Directors and providers to align on clinical decisions; Document reviews accurately and meet production/quality goals; Apply MCG, Cohere, and coverage guidelines to ensure compliance and consistency; Partner across teams to improve processes and outcomes; Identify opportunities for care management or quality improvement programs
Seniority
Mid-level, hands-on IC