The clinician reviews medical records, treatment plans, and service requests to determine whether care is medically necessary and appropriate under established utilization management criteria. The work is mostly remote and includes coordination with physicians, management teams, and clients to support timely, high-quality case decisions. This PRN role also involves maintaining documentation in medical management systems and supporting process improvements for review turnaround and quality.
Key Responsibilities
- Conduct utilization reviews and assess medical necessity using established criteria and evidence-based guidelines.
- Review patient records and treatment plans to evaluate the appropriateness and quality of services provided.
- Provide clinical guidance to non-clinical staff and serve as a clinical resource on review decisions.
- Enter, manage, and update clinical information in medical management platforms.
- Communicate findings and recommendations with physicians, management teams, and the Medical Director.
- Participate in quality improvement efforts, including process refinement and case finalization for client release.
- Coordinate quality issue reports and new reviewer reports with clinical operations leadership.
Required
- Active, unrestricted LVN/LPN or RN license.
- At least 2 years of clinical nursing experience.
- At least 1 year of prior utilization management experience.
- Ability to communicate effectively in writing and verbally.
- Proficiency with Microsoft Word, Excel, PowerPoint, Outlook, and other computer systems.
Preferred
- Experience working with utilization review criteria such as CMS, Milliman Care Guidelines, InterQual, or health plan-specific guidelines.
- Experience in a dynamic office or remote work environment.
- Familiarity with medical management or case review platforms.
Benefits & Perks
- PRN scheduling with required weekend and holiday coverage.
- Work-from-home setup with required internet connectivity.
- Apple equipment and a media stipend for the remote workspace.
- Medical, dental, and vision coverage.
- Voluntary life insurance options for employee and family members.
- Basic life insurance, short-term disability, and long-term disability coverage at no cost.
- Paid time off.
- 401(k) plan with company match.
- Performance bonuses.