Care Review Clinician (RN) Remote

Job Overview

Job Description

## Care Review Clinician (RN) Remote

The **Care Review Clinician (RN)** is responsible for reviewing medical records and clinical information to determine the medical necessity and appropriateness of healthcare services. The role typically involves conducting utilization and care reviews, collaborating with providers, and ensuring members receive appropriate, cost-effective, and quality care while following established clinical guidelines and regulatory requirements.

### Key Responsibilities

- Review medical records, clinical documentation, and authorization requests to determine medical necessity.
- Conduct prospective, concurrent, and retrospective utilization reviews.
- Apply established clinical criteria, policies, and evidence-based guidelines to care decisions.
- Evaluate inpatient, outpatient, emergency, and other healthcare services as applicable.
- Communicate with physicians, hospitals, healthcare providers, and internal clinical teams regarding clinical reviews.
- Request additional clinical information when documentation is incomplete.
- Identify opportunities for appropriate care coordination and improved member outcomes.
- Escalate cases that require physician or medical-director review.
- Document clinical determinations, interventions, and communications accurately in applicable systems.
- Ensure decisions comply with organizational policies, state and federal regulations, and accreditation standards.
- Support quality improvement, cost management, and member safety initiatives.
- Maintain confidentiality and protect member health information in accordance with HIPAA requirements.

### Qualifications

- Active **Registered Nurse (RN) license**; additional state licenses may be required for remote work.
- Nursing degree and relevant clinical experience.
- Experience in utilization management, case management, care coordination, or clinical review preferred.
- Knowledge of medical necessity criteria and healthcare regulations.
- Strong clinical assessment, documentation, communication, and critical-thinking skills.
- Ability to work independently, manage multiple cases, and meet productivity and turnaround-time requirements.
- Experience with electronic medical records and clinical/healthcare management systems preferred.