clinical review nurse

Centene

<div>You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. 
Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member.<ul><li>
Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care</li>
<li>Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member</li>
<li>Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered</li>
<li>Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines</li>
<li>Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings</li>
<li>Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members</li>
<li>Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines</li>
<li>Reviews member&rsquo;s transfer or discharge plans to ensure a timely discharge between levels of care and facilities</li>
<li>Collaborates with care management on referral of members as appropriate</li><li>
Performs other duties as assigned.</li>
<li>Complies with all policies and standards.</li></ul>
We are seeking a Clinical Review Nurse - Concurrent Review to join our team!
The ideal candidate will bring expertise in:
IL Nursing License
 
Concurrent Review
 
Inpatient Authorizations 
Discharge Planning 
Acute and/or Critical Care
 
Computer Savvy
 
Excellent Customer Service and Communication Skills
Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor&rsquo;s degree in Nursing and 2 &ndash; 4 years of related experience. 2+ years of acute care experience required. 
 
Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. 
Knowledge of Medicare and Medicaid regulations preferred. 
Knowledge of utilization management processes preferred. 
 
License/Certification:<ul><li>
LPN - Licensed Practical Nurse - State Licensure required</li></ul>
Pay Range: $27.02 - $48.55 per hour
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. 
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act</div>

Clinical Review Nurse - Concurrent Review

Palm Medical Centers

<div>Position Summary: 
The Concurrent Review Nurse is responsible for performing utilization management activities to ensure medical services are delivered effectively, efficiently, and appropriately. This includes reviewing inpatient admissions and ongoing hospital stays to determine medical necessity, appropriateness of care, and length of stay in accordance with clinical guidelines and payer requirements. 
 
Key Responsibilities:<ul><li>
Conduct timely and accurate concurrent reviews of inpatient hospitalizations and other levels of care.</li><li>
Evaluate clinical documentation against evidence-based criteria (e.g., InterQual&reg;, MCG) to determine medical necessity and appropriate level of care.</li><li>
Collaborate with physicians, hospital staff, and insurance companies to coordinate patient care and discharge planning.</li><li>
Communicate utilization review decisions and recommendations to providers and payers.</li><li>
Document all reviews, decisions, and communications in accordance with regulatory and organizational standards.</li><li>
Identify cases requiring escalation or peer review and follow established procedures.</li><li>
Ensure compliance with CMS guidelines, accreditation standards (e.g., NCQA, URAC), and HIPAA.</li><li>
Participate in quality improvement initiatives and departmental meetings</li></ul>
Qualifications: 
 
Education &amp; Licensure:<ul><li>
Registered Nurse (RN) license, active and in good standing, required.</li><li>
Associate or Bachelor&rsquo;s degree in nursing (BSN preferred).</li></ul>
Experience:<ul><li>
Minimum 2 years of clinical experience (e.g., med-surg, critical care).</li><li>
At least 1 year of utilization review, case management, or managed care experience preferred.</li></ul>
Skills &amp; Competencies:<ul><li>
Knowledge of InterQual&reg;, MCG, or other clinical review guidelines.</li><li>
Familiarity with Medicare/Medicaid and commercial insurance regulations.</li><li>
Strong analytical and clinical judgment skills.</li><li>
Effective communication and negotiation skills.</li><li>
Proficient with electronic medical records (EMRs) and utilization review platforms.</li><li>
Detail-oriented with excellent organizational skills.</li></ul>
Work Environment:<ul><li>
Remote</li></ul> 
Palm Primary Care is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment of any kind based on race, color, sex, religion, sexual orientation, national origin, disability, genetic information, pregnancy, or any other protected characteristic as outlined by federal, state, or local laws. 
 
This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, training, and apprenticeship. Palm Primary Care makes hiring decisions based solely on qualifications, merit, and business needs at the time.
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Concurrent Review Nurse

HMSA

<div>
 
 Employment Type
 
 
 
 Full-time
 
 
 
 Exempt or Non-Exempt
 
 
 
 Exempt
 
 
 
 Job Summary
 
 
 
 
 Hybrid Work Environment - Must reside in Hawaii
 
 
 
 
 Pay Range:
 
 $59,000 to $116,000
 
 
 
 Note
 
 : Individuals typically begin between the minimum to middle of the pay range
 
 
 Under minimal supervision, conducts detailed analysis and review of precertification requests, post-service and suspended claims, by applying clinical expertise against HMSA medical and reimbursement policies, plan benefits and nationally accepted clinical guidelines to determine appropriateness of care for all HMSA lines of business.
 
 
 
 Minimum Qualifications
 
 
 
 <ul>
 <li>
 Associates degree in Nursing.
 </li>
 <li>
 Current, unrestricted Nursing License in the state of Hawaii as an RN or LPN.
 </li>
 <li>
 Two years clinical, case management or utilization management related experience.
 </li>
 <li>
 Knowledge of current standards of care to be followed for a given diagnosis and the normative values of medical tests and procedures.
 </li>
 <li>
 Strong organizational skills
 </li>
 <li>
 Good communication skills both verbally and written
 </li>
 <li>
 Analytical skills
 </li>
 <li>
 Basic knowledge of Microsoft Office applications. Including but not limited to Word, Excel, and Outlook.
 </li>
 <li>
 Currently licensed in Hawaii as an RN or LPN
 </li>
 <ul>
 <li>
 (if applicable upon hire, proof of licensure to be provided by employee or confirmed by Human Resources)
 
 </li>
 </ul>
 </ul>
 
 Duties And Responsibilities
 
 
 
 <ul>
 <li>
 Utilize medical necessity criteria from established medical policies and clinical practice guidelines to render precertification determinations as described in the Medical Management UM work plan. This detailed clinical judgment includes evaluating whether the requested service is a covered benefit under the member's health plan, is medically appropriate for the member's clinical condition or whether the request requires referral to a Medical Director for potential denial of the request. The Nurse Reviewer must follow each line of business' requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each request. Assists on inquiries from external parties such as the State Insurance Commissioner and from the Legal Department. Responsibilities include, but are not limited to:
 </li>
 <ul>
 <li>
 Demonstrate understanding and application of over 250 Guide to Benefits, Evidence of Coverage, Plan Brochure, and Member Handbook. HMSA annually updated medical and drug policies, medical protocols, National Comprehensive Cancer Network, Milliman Care Guidelines, Drugdex, etc. to determine the medical necessity of urgent and non-urgent precertification requests. Urgent requests must be completed within 72 hours and non-urgent requests within 15 calendar days.
 </li>
 <li>
 Use clinical judgment, medical necessity guidelines and plan benefits to determine approval, potential denial or alternative treatment of each urgent or non-urgent precertification request. Settings include inpatient, outpatient, in-state, out-of state and out-of country.
 </li>
 <li>
 Document clinical case summary and review outcome of each review appropriately to meet regulatory and program requirements.
 </li>
 <li>
 Review various types of services, including but not limited to:
 </li>
 <li>
 Transplants
 </li>
 <li>
 Air Ambulance
 </li>
 <li>
 Chemotherapy
 </li>
 <li>
 Clinical trials
 </li>
 <li>
 Genetic testing
 </li>
 <li>
 Cancer treatments/radiation therapy
 </li>
 <li>
 Experimental/Investigational Services/Devices
 </li>
 <li>
 New Technology
 </li>
 </ul>
 <li>
 Utilize medical necessity criteria from established medical policies and clinical practice guidelines to render precertification determinations as described in the Medical Management UM work plan. This detailed clinical judgment includes evaluating whether the requested service is a covered benefit under the member's health plan, is medically appropriate for the member's clinical condition or whether the request requires referral to a Medical Director for potential denial of the request. The Nurse Reviewer must follow each line of business' requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each request. Assists on inquiries from external parties such as the State Insurance Commissioner and from the Legal Department. Responsibilities include, but are not limited to:
 </li>
 <ul>
 <li>
 Call providers when additional clinical information is required to clarify or complete a complex precertification determination.
 </li>
 <li>
 Approve precertification requests based on clinical judgment using criteria, medical record documentation and other information received from the provider.
 </li>
 <li>
 Consult with Medical Directors on requests which do not meet clinical criteria and offer alternative covered health care options as appropriate.
 </li>
 <li>
 Consult Medical Directors on potential quality issues identified during review of medical records. Refer cases to Integrated Health Management, Pharmacy Department or Benefits Integrity Department depending on the concern.
 </li>
 </ul>
 <li>
 Evaluate suspended claims against medical records to determine the medical necessity and appropriateness of medical services, identify irregularities such as over or under-utilization of services, potential up-coding, over billing, etc.
 </li>
 <li>
 Communicate timely, accurate information either verbally, electronically or in writing using clinical judgment, knowledge of medical/reimbursement policies and plan benefits to providers, members as well as internal MM staff and other internal departments (Claims Administration, Customer Relations, Provider Contracting, etc.). For denied services, ensure the denial, benefit and appeal language are accurate and consistent with department procedures, accreditation and regulatory guidelines.
 </li>
 <li>
 Identify and refer members with specific medical and/or behavioral health needs or complex case management and collaborate with medical and behavioral case management staff. Identify and refer quality of care issues and suspected fraud, waste or abuse to the appropriate departments.
 </li>
 <li>
 Perform pre-screening assessment of incoming pre-certification requests to ensure appropriateness of review. Advises non-clinical staff on clinical and coding questions to ensure correct system processes and entries.
 </li>
 <li>
 Performs all other miscellaneous responsibilities and duties as assigned or directed.
 
 
 </li>
 </ul>
</div>

Nurse Reviewer - Clinical Review Unit

VanderHouwen

<div>
 Our client is seeking a detail-oriented and clinically strong Registered Nurse who excels at applying sound judgment to complex healthcare scenarios. This individual will bring a balance of analytical thinking, regulatory awareness, and clear communication to ensure fair and accurate appeal outcomes. The ideal candidate is collaborative, adaptable, and confident navigating both clinical and non-clinical conversations in a remote environment.
 
 
 
 This role is a Hybrid model in Idaho. Applicants must be able to maintain flexibility to occasionally support work outside of standard business hours may be required.
 
 
 
 
 Clinical Appeals Nurse (RN) Responsibilities
 
 
 
 <ul>
 <li>
 Conduct comprehensive clinical reviews of member and provider appeals, ensuring alignment with medical necessity, policies, and standards of care.
 </li>
 <li>
 Apply clinical expertise to interpret medical records, benefit plans, and contractual requirements to support accurate determinations.
 </li>
 <li>
 Collaborate with physician advisors when needed to validate complex or high-risk clinical decisions.
 </li>
 <li>
 Ensure all appeal decisions meet regulatory, accreditation, and organizational compliance requirements.
 </li>
 <li>
 Provide guidance and education to non-clinical team members on clinical aspects of appeals and case reviews.
 
 
 </li>
 </ul>
 
 Clinical Appeals Nurse (RN) Qualifications
 
 
 
 <ul>
 <li>
 Must hold a current, unrestricted Registered Nurse (RN) license in Oregon, Washington, Idaho, or Utah; Bachelor&rsquo;s degree in Nursing preferred.
 </li>
 <li>
 Minimum of 2 years of experience in health insurance, utilization management, or clinical appeals review, plus at least 3 years of direct patient care experience.
 </li>
 <li>
 Strong knowledge of medical terminology, procedures, coding systems (CPT, ICD, HCPCS), and clinical guidelines (e.g., MCG).
 </li>
 <li>
 Proven ability to interpret medical records, claims, and benefit structures, and translate findings into clear, concise written determinations.
 </li>
 <li>
 Familiarity with regulatory and accreditation standards, along with proficiency in Microsoft Office tools and remote work environments.
 
 
 </li>
 </ul>
 
 Compensation: $28-$30/hr. (DOE)
 
 
 VanderHouwen Contractors Enjoy Exceptional Benefit Perks!
 
 
 
 As an eligible contract employee with VanderHouwen, you'll have access to a full suite of benefits designed with your well-being in mind. Our comprehensive package includes medical, dental, vision, life insurance, short- and long-term disability, and a matching 401(k) to help secure your future.
 
 
 
 Meet VanderHouwen
 
 
 
 What kind of recruiter do you see yourself working with? One who prioritizes your best interest, no matter what? VanderHouwen does, and we're in it for the long game! Our recruiters focus on YOU, building meaningful, long-term relationships while developing a deep understanding of companies' staffing needs and workplace cultures. This approach helps us find an ideal job match that aligns with your unique career aspirations and goals.
 
 
 VanderHouwen is an award-winning, Women &amp; Diversity-Owned, WBENC certified professional staffing firm. Founded in 1987, VanderHouwen places experienced professionals across the nation! Our recruitment teams specialize in either Technology and IT, Engineering, Human Resources, or Accounting and Finance career markets. Partner with us to land your next exciting career!
 
 
 VanderHouwen is an Equal Opportunity Employer and participates in E-Verify. VanderHouwen does not discriminate based on race, color, religion, sex, national origin, age, disability, or any other characteristic protected by applicable local, state, or federal civil rights laws.
 
 
</div>

Clinical Appeals Nurse (RN)

Liberty Healthcare Corporation

<div>Registered Nurses are encouraged to consider a full-time Clinical Reviewer position with Liberty Healthcare.

As a Clinical Reviewer, you will be an active contributor with a large-scale program which endeavors to enrich the lives of older adults and people who are living with developmental disabilities.

Your role will focus on the review and analysis of health information of recipients of Medicaid HCBS waiver services, and your day-to-day responsibilities will include:
<ul>
<li>Reviewing medical records and personal health information</li>
</ul><ul><li>Conducting root cause analyses of critical incidents and deaths</li>
</ul><ul><li>Forming objective evidence-based opinions</li>
</ul><ul><li>Writing detailed reports</li>
</ul><ul><li>Leading and participating in committee and team meetings</li>
</ul><ul><li>Providing technical assistance and training</li>
</ul><ul><li>Collaborating with stakeholders</li>
</ul>
This is a remote-first position which will primarily allow you to work in your home office with an occasional need to attend in-person meetings in Nebraska. This is a non-direct care role which does not involve patient contact or nursing care.

As a valued full-time employee of Liberty Healthcare and Clinical Reviewer, you can expect:
<ul>
<li>$80,000 annual salary</li>
</ul><ul><li>Health insurance, dental insurance, vision insurance, life insurance, and disability insurance</li>
</ul><ul><li>30 days of paid time off each year for holidays, vacation, sick leave, and personal days</li>
</ul><ul><li>Health Savings Account, 401k plan, and other perks</li>
</ul>
Full details on Liberty's benefits plan are available at www.libertyhealthcare.com/upload/138.pdf
You are a good fit for this position if you possess the following:
<ul>
<li>Professionally licensed as a Registered Nurse in Nebraska</li>
</ul><ul><li>Experience providing nursing services to older adults and people who are living with developmental disabilities</li>
</ul><ul><li>Knowledge of quality assurance methodologies
</li></ul><ul><li>Outstanding analytical and report writing skills</li>
</ul><ul><li>Nebraska residency</li>
</ul>
Liberty Healthcare is an equal opportunity employer committed to diversity, equity, and inclusion. Our organization is composed of, and proudly serves, people of diverse backgrounds and abilities.

Click &ldquo;Apply&rdquo; and submit your resume for immediate consideration.</div>

Registered Nurse – Clinical Reviewer

Molina Healthcare

<div>
 JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care.
 
 
 
 Essential Job Duties
 
 
 
 <ul>
 <li>
 Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines.
 </li>
 <li>
 Analyzes clinical service requests from members or providers against evidence based clinical guidelines.
 </li>
 <li>
 Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.
 </li>
 <li>
 Conducts reviews to determine prior authorization/financial responsibility for Molina and its members.
 </li>
 <li>
 Processes requests within required timelines.
 </li>
 <li>
 Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner.
 </li>
 <li>
 Requests additional information from members or providers as needed.
 </li>
 <li>
 Makes appropriate referrals to other clinical programs.
 </li>
 <li>
 Collaborates with multidisciplinary teams to promote the Molina care model.
 </li>
 <li>
 Adheres to utilization management (UM) policies and procedures.
 
 
 </li>
 </ul>
 
 Required Qualifications
 
 
 
 <ul>
 <li>
 At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience.
 </li>
 <li>
 Registered Nurse (RN). License must be active and unrestricted in state of practice.
 </li>
 <li>
 Ability to prioritize and manage multiple deadlines.
 </li>
 <li>
 Excellent organizational, problem-solving and critical-thinking skills.
 </li>
 <li>
 Strong written and verbal communication skills.
 </li>
 <li>
 Microsoft Office suite/applicable software program(s) proficiency.
 
 
 </li>
 </ul>
 
 Preferred Qualifications
 
 
 
 <ul>
 <li>
 Certified Professional in Healthcare Management (CPHM).
 </li>
 <li>
 Recent hospital experience in an intensive care unit (ICU) or emergency room.
 
 
 </li>
 </ul>
 To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
 
 
 Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V
 
 
 Pay Range: $27.73 - $54.06 / HOURLY
 
 
 <ul>
 <li>
 Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
 </li>
 </ul>
</div>

Care Review Clinician (RN)

Search 10000+ Clinical review nurse jobs near you this April. New roles added regularly across leading industries. Apply today.

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