This role supports care review activities for members by evaluating clinical information, applying coverage criteria, and helping coordinate appropriate services and next steps. The work is primarily utilization or care management focused rather than direct bedside care, with ongoing collaboration across clinical and nonclinical teams.
Key Responsibilities
- Conduct clinical reviews of member cases, medical records, and supporting documentation.
- Apply established criteria and organizational guidelines to determine appropriate care recommendations.
- Coordinate with care management, providers, and other internal teams to support timely member transitions and service decisions.
- Document review findings, determinations, and follow-up actions accurately in clinical systems.
- Participate in case discussion and escalation workflows for complex or borderline cases.
Required
- Active RN licensure.
- Experience in clinical review, utilization management, care management, or a related nursing role.