RN Care Review Specialist — Utilization & Care Coordination

Folioworks; Kentucky; On-site; USD 65,000 - 90,000; Full time

Job summary

Folioworks in Kentucky is seeking a registered nurse to conduct clinical reviews of member cases, apply criteria, and coordinate appropriate care. This role focuses on utilization management and care coordination rather than bedside care.

You will document findings in clinical systems, collaborate with care management and providers, and participate in escalation workflows for complex cases. Active RN licensure and experience in clinical review are required.

Qualifications

• Active RN licensure.
• Experience in clinical review, utilization management, or care management.

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.

Education

RN licensure

Job description

Folioworks in Kentucky is seeking a registered nurse to conduct clinical reviews of member cases, apply criteria, and coordinate appropriate care. This role focuses on utilization management and care coordination rather than bedside care.

You will document findings in clinical systems, collaborate with care management and providers, and participate in escalation workflows for complex cases. Active RN licensure and experience in clinical review are required.