This role focuses on advanced clinical review for complex cases, using nursing judgment to determine medical necessity, interpret clinical information, and support care decisions for members. The clinician also collaborates with providers and case management staff, supports discharge planning and member education, and helps guide appropriate care pathways and benefit use. In addition, the position contributes to policy, quality improvement, documentation accuracy, and training for other nurses.
Key Responsibilities
- Conduct complex case reviews to determine medical necessity for requested services.
- Evaluate member symptoms, clinical data, and provider input to support holistic clinical assessment.
- Collaborate with healthcare providers to clarify clinical context and optimize care decisions.
- Consult with medical directors on unclear, atypical, or high-complexity cases.
- Coordinate discharge planning support with case management nurses, including equipment, environment, and patient education needs.
- Educate members on plan benefits, provider options, and care pathways.
- Participate in policy development, workflow improvement, and cross-functional initiatives.
- Conduct quality reviews, support corrective action planning, and ensure documentation and compliance standards are met.
Required
- Active, unrestricted RN license in an applicable U.S. state.
- Multi-state licensure if serving members across multiple states.
- Associate’s degree in Nursing at minimum.
- 4+ years of care management or case management experience.
- 2+ years of clinical, utilization review, or managed care experience, or an equivalent combination of education and experience.
- Ability to interpret complex clinical information and apply evidence-based criteria.
- Proficiency with EMR systems.
Preferred
- Experience working in managed care or utilization review settings.
- Background supporting complex case management or discharge planning.
- Experience with quality audits, policy development, or staff training.
Benefits & Perks
- Primarily work from home with onsite attendance only for onboarding, training, or as required by management.
- Training and onboarding support are provided.
- Opportunity to contribute to organizational policy, quality improvement, and cross-functional initiatives.
- Role includes mentorship and clinical resource responsibilities for other nurses.