Clinical Reviewer

Position Overview

We are seeking a Clinical Utilization Review Nurse (RN) to assess the medical necessity and quality of healthcare services through prospective, concurrent, and retrospective utilization management reviews. This full-time, remote position supports high-quality, appropriate, and cost-effective care while ensuring compliance with clinical criteria, organizational policies, and contract requirements specific to New Mexico.

Key Responsibilities

• Conduct prospective, concurrent, and retrospective utilization management reviews
• Apply clinical review criteria, organizational policies, guidelines, and screening tools (InterQual)
• Consult with physician/practitioner consultants when services do not meet medical necessity criteria
• Collaborate with internal teams and refer cases for additional review or escalation as appropriate
• Provide clinical and utilization review subject matter expertise
• Respond to provider, customer, and stakeholder questions regarding determinations and processes
• Conduct outreach to providers, case managers, consultants, and community support coordinators to obtain additional clinical information
• Maintain accurate documentation and comply with all regulatory and contract standards

Education & Experience

• BA/BS in Nursing or equivalent combination of education and/or related experience
• Equivalent combination of education and/or related experience may be considered depending on contract
• Minimum of 3 years of direct patient care (clinical) experience
• Licensure: Current, active, unrestricted RN license
• Must meet New Mexico state and contract-specific requirements

Required Skills & Competencies

• Experience with InterQual Criteria
• Strong proficiency in Microsoft Office Suite and familiarity with database systems
• Excellent written and verbal communication skills
• Strong organizational, analytical, and problem-solving abilities
• Ability to manage multiple priorities in a fully remote, team-based environment

Benefits

• Medical, dental and vision insurance
• Paid time off for vacation, illness, and volunteering
• Retail savings plan with employer contribution
• Adoption financial assistance
• Paid parental leave
• And much more!

Work Environment

• Full-Time
• 100% Remote (United States)
• Reliable, secure internet connection required
• Requires a workspace free from significant distractions
• Frequent use of computers, phones, and virtual communication tools
• Employees must be able to sit for extended periods, communicate effectively
• Some positions may require operating a motor vehicle for business purposes; in such cases, employees must maintain a valid driver’s license and meet the organization’s driving eligibility requirements
• Occasional travel may be required for meetings, training, or other work-related events
• Reasonable accommodations will be provided to enable individuals with disabilities to perform essential functions