Clinical Utilization Review RN

Clearlink Partners; United States; On-site; USD 70,000 - 100,000; Full time

Job summary

Clearlink Partners in the United States seeks an experienced Registered Nurse to perform medical reviews and utilization management within a managed care setting, emphasizing evidence-based determinations and timely documentation to support access and quality. The ideal candidate has a Compact RN license, 5+ years of acute care experience, and at least 2 years in a multi-line managed care environment.

HMO/risk contracting knowledge and strong communication are preferred.

Qualifications

• Current unencumbered Compact RN license.
• Minimum 5+ years of acute clinical experience.
• Minimum 2 years in a managed care environment across multiple lines of business (Medicare Advantage, Managed Medicaid, etc.).
• HMO and risk contracting experience preferred.
• Excellent oral and written interpersonal/communication skills.

Responsibilities

• Determine appropriateness of services through guidelines and benefit determinations.
• Perform 15-30 reviews per day.
• Conduct initial and concurrent reviews of inpatient admissions.
• Review outpatient surgeries and ancillary services.
• Conclude medical necessity and appropriateness using clinical criteria.
• Collaborate with Medical Directors for referrals and complex cases.
• Document all review determinations with providers and members.

Skills

RN license

Acute care

Managed care

Communication

Education

Compact RN license

Tools

Microsoft Office

Job description

Clearlink Partners in the United States seeks an experienced Registered Nurse to perform medical reviews and utilization management within a managed care setting, emphasizing evidence-based determinations and timely documentation to support access and quality. The ideal candidate has a Compact RN license, 5+ years of acute care experience, and at least 2 years in a multi-line managed care environment.

HMO/risk contracting knowledge and strong communication are preferred.