Remote RN: Clinical Review & Utilization Mgmt

MotivHealth; Utah; On-site; USD 90,000 - 115,000; Full time

Benefits offered by this job

Annual bonus

Health, vision, dental insurance

HSA contribution

Wellness program

Retirement plan

PTO

10 holidays

Job summary

MotivHealth is seeking a Clinical Review Nurse (RN) to support care management by conducting clinical reviews, ensuring appropriate utilization of services, and ensuring compliance with regulatory and plan guidelines. This remote role is open to candidates residing in Utah, Texas, or Arizona.

You will perform medical necessity reviews, apply evidence-based guidelines, and collaborate with clinicians to inform determinations.

Qualifications

• Current, unrestricted RN license for Utah or compact license.
• portions of description may be adjusted

Responsibilities

• Perform prospective, concurrent, and retrospective medical necessity reviews for inpatient, outpatient, and ancillary services.
• Apply evidence-based guidelines (MCG, InterQual) to determine medical necessity and appropriateness of care.
• Collaborate with physicians, providers, and other healthcare professionals regarding clinical determinations.
• Ensure timely processing of pre-certification, prior authorization, and concurrent review requests.
• Document clinical findings and review outcomes in utilization management systems.
• Identify potential quality-of-care issues and escalate appropriately.
• Support case management teams in coordinating care for members with complex health needs.
• Assist in transitions of care to reduce readmissions.
• Provide education to members and providers on coverage, benefits, and clinical guidelines.
• Ensure adherence to regulatory requirements and accreditation standards.
• Maintain PHI confidentiality per HIPAA; participate in audits and quality initiatives.

Skills

RN license

Utilization mgmt

Clinical review

InterQual

MCG

EMR software

Microsoft Office

Communication

Critical thinking

Tools

EMR software

Microsoft Office

Job description

MotivHealth is seeking a Clinical Review Nurse (RN) to support care management by conducting clinical reviews, ensuring appropriate utilization of services, and ensuring compliance with regulatory and plan guidelines. This remote role is open to candidates residing in Utah, Texas, or Arizona.

You will perform medical necessity reviews, apply evidence-based guidelines, and collaborate with clinicians to inform determinations.