Clinical Review Nurse - Remote

We are seeking a detail-oriented and clinically skilled Clinical Review Nurse to join our team in a fully remote role. The role involves conducting medical necessity reviews, evaluating clinical documentation, assessing healthcare services, and ensuring compliance with established clinical guidelines, regulatory requirements, and organizational policies.

Responsibilities

• Perform clinical reviews to determine medical necessity, appropriateness of care, and level of service.
• Review medical records, provider documentation, treatment plans, and related clinical information.
• Apply evidence-based guidelines, regulatory standards, and company policies during the review process.
• Collaborate with physicians, healthcare providers, case managers, and other interdisciplinary teams.
• Document review findings thoroughly and accurately within designated systems.
• Identify opportunities to improve quality of care, member outcomes, and cost-effective healthcare delivery.
• Ensure compliance with federal, state, and accreditation requirements.
• Participate in audits, quality improvement initiatives, and process enhancements.
• Maintain productivity, quality, and turnaround-time standards.
• Stay current on clinical best practices, healthcare regulations, and review criteria.

Requirements

• Active, unrestricted compact Registered Nurse (RN) license in good standing.
• Associate's or Bachelor's degree in Nursing.
• 2+ years of experience in Utilization Management.
• Experience with Medicare, Medicaid, Commercial Health Plans, or Managed Care programs.
• Knowledge of InterQual, MCG, or other clinical decision-support guidelines.

Pay

The pay range for this position is $34.00 - $40.00/hr. Individual compensation offered within this range will depend on qualifications, skills, relevant experience, job knowledge, geographic location, internal equity, and other pertinent job-related factors.

Benefits

Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include:

• Medical, dental, and vision insurance.
• Critical Illness, Accident, and Hospital coverage.
• 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available.
• Life Insurance (Voluntary Life & AD&D for the employee and dependents).
• Short- and long-term disability.
• Health Spending Account (HSA).
• Transportation benefits.
• Employee Assistance Program.
• Time Off/Leave (PTO, Vacation, or Sick Leave).

Schedule

This is a Contract to Hire position based out of St. Louis, MO, and is fully remote.