Clinical Review Registered Nurse

Strategic Staffing Solutions; Burlington (VT); Remote; USD 60,000 - 95,000; Full time

Job summary

An established industry player is seeking a Clinical Review Registered Nurse for a short-term remote assignment in Vermont. This role is crucial for executing utilization management processes, ensuring high-quality care through clinical reviews. The ideal candidate will have extensive clinical nursing experience and a strong background in utilization review. You will engage in critical decision-making, collaborate with medical directors, and support provider relations. If you're passionate about enhancing healthcare delivery and thrive in a dynamic environment, this opportunity is perfect for you.

Qualifications

• 5+ years of clinical/hospital RN experience.
• 2+ years of Utilization Review/Management experience.

Responsibilities

• Conduct clinical reviews of prior approval and claims requests.
• Assess clinical information for decision-making based on policies.
• Communicate with providers to obtain additional information.

Skills

Clinical Nursing

Utilization Review

Clinical Judgment

Communication Skills

Education

Compact Nursing License

Job description

Job Title: Clinical Review Registered Nurse

Join us at Strategic Staffing Solutions for an exciting opportunity as a Clinical Review Registered Nurse.

Position Details:

• Type: W2 Contract
• Location: Remote in Vermont
• Duration: 3 months (short-term assignment)

Position Summary: This role involves executing utilization management processes to ensure delivery of medically necessary, appropriate, and high-quality care through clinical reviews. Responsibilities include reviewing requests against medical necessity criteria, identifying questionable cases, and referring them to medical directors as needed.

Required Experience:

• 5+ years of clinical/hospital RN experience
• Compact Nursing License
• 2+ years of Utilization Review/Management experience

Primary Responsibilities:

• Conduct clinical reviews of prior approval, post-service reviews, and claims requests.
• Assess clinical information for decision-making based on policies and guidelines.
• Communicate with providers to obtain additional information.
• Review out-of-network authorizations for appropriateness.
• Provide timely reviews for procedures/services and participate in audits.
• Use clinical judgment and review criteria to determine medical necessity.
• Support provider relations and reimbursement teams with clinical issues.
• Refer complex cases to medical directors and report quality issues.
• Maintain case documentation accurately and participate in policy development.

Important Notes: Beware of scams; S3 does not ask for money during onboarding.

Job ID: JOB-241276

Publish Date: 29 Apr 2025

Additional Details:

• Seniority Level: Mid-Senior level
• Employment Type: Contract
• Job Function: Healthcare Provider