Jobs 1 - 20 out of 49 for Clinical Review Nurse

Review prior authorization requests to determine medical necessity of services and appropriate level of care. Ensure compliance with national standards and member benefit coverage. Evaluate complex cases and collaborate with the medical team for clinical decisions.

Review prior authorization requests to determine medical necessity and appropriate level of care. Evaluate requests in accordance with national clinical standards and member benefit coverage. Assess complex authorization cases and provide recommendations. Support utilization management processes and...

Review clinical charts for medical necessity in inpatient admissions, conduct concurrent reviews, utilize InterQual for assessments, and make appropriate referrals based on clinical presentations.

Performs concurrent reviews to determine member's overall health, evaluates medical necessity, and contributes to discharge planning. Assists in evaluating inpatient services and collaborates with healthcare providers to approve medical determinations.

Analyzes prior authorization requests to determine medical necessity of service and appropriate level of care. Provides recommendations to the medical team, performs medical necessity reviews, coordinates with healthcare providers, escalates requests to Medical Directors, assists with service author...

Performs concurrent reviews to determine member's overall health, evaluates medical necessity, and contributes to discharge planning. Assists in evaluating inpatient services and collaborates with healthcare providers to approve medical determinations. Collects and maintains concurrent review findin...

Performs concurrent reviews to determine member's overall health, evaluates medical necessity, and contributes to discharge planning. Assists in evaluating inpatient services and collaborates with healthcare providers to approve medical determinations. Collects and maintains concurrent review findin...

Conduct inpatient concurrent reviews to assess medical necessity using InterQual criteria and corporate policies. Perform reviews of member care, evaluate medical necessity, and contribute to discharge planning. Collaborate with healthcare providers and assist in providing education on utilization p...

Performs concurrent reviews to determine member's overall health, evaluates medical necessity, and contributes to discharge planning. Reviews quality and continuity of care, works with Medical Affairs, collects and documents review findings, and collaborates with care management on referrals.

Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care. Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member. Works with Medical Affairs and/o...

Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and ...

Performs concurrent reviews to determine member's overall health, evaluates medical necessity, and contributes to discharge planning. Reviews inpatient services for necessity and setting of care, collaborates with healthcare providers, and documents findings in health management systems.

Performs concurrent reviews to determine member's overall health, evaluates medical necessity, and contributes to discharge planning. Assists in evaluating inpatient services and collaborates with healthcare providers to approve medical determinations. Collects and maintains review findings and disc...

Performs concurrent reviews to determine member's overall health, evaluates medical necessity, and contributes to discharge planning. Assists in evaluating inpatient services and collaborates with healthcare providers to approve medical determinations. Collects and maintains review findings and disc...

Performs concurrent reviews to determine member's overall health, evaluates medical necessity, and contributes to discharge planning. Assists in evaluating inpatient services, reviews quality and continuity of care, collects and maintains review findings, and collaborates with healthcare providers a...

Responsible for ensuring case reports are of the highest quality and integrity and in full compliance with client contractual agreements, regulatory agency standards and federal and state mandates. Perform quality assurance review of peer review reports, ensure clear, concise, evidence-based rationa...

Review outpatient authorization requests, assess medical necessity, apply clinical guidelines, and ensure members receive timely and appropriate access to care. Collaborate with providers and interdisciplinary teams, perform medical necessity reviews, coordinate with healthcare providers, and mainta...

Perform medical necessity reviews of inpatient admissions and continued stays. Apply clinical criteria and guidelines such as InterQual, internal clinical policies, and plan-specific requirements. Communicate with hospitals and review clinical documentation. Make authorization determinations within ...

Reviews inpatient admissions and elective procedures to determine medical necessity. Performs concurrent reviews, evaluates medical necessity, and contributes to discharge planning. Works with healthcare providers to approve medical determinations and provides education on utilization processes. Col...

The Clinical Review Nurse Care Manager utilizes clinical expertise, evidence-based guidelines, insurance knowledge, business acumen, and high level of communication skills to ensure appropriate utilization of and reimbursement for resources from admission through hospital stay to discharge. Adeptly ...