Job Description

The RN Reviewer is responsible for performing prospective, concurrent, and retrospective reviews to determine the medical appropriateness of clinical requests. This role involves collaboration with Medical Directors and providers, documentation of reviews, and application of clinical guidelines to ensure cost-effective and high-quality care.

Responsibilities

• Review medical necessity for inpatient and outpatient cases
• Collaborate with Medical Directors and providers
• Document reviews accurately
• Apply MCG, Cohere, and coverage guidelines
• Improve processes and outcomes
• Identify opportunities for care management
• Support accreditation and quality initiatives

Requirements

• Active, unencumbered RN license
• 3+ years of clinical experience
• Utilization Management experience
• Experience in acute or post-acute settings
• Proficiency with Mac and Google Workspace
• Strong communication and collaboration skills
• Adaptability in a fast-moving environment

Benefits

• No benefits