Job Title: Registered Nurse Review Analyst
Location: Remote
Duration: 12-Month Contract
Department: MA Inpatient Precertification
Pay Rate: $30-$40/hour
Work Arrangement
- Fully Remote
- No onsite requirements anticipated during the assignment.
Position Overview
- We are seeking a Registered Nurse Review Analyst to support inpatient precertification and utilization management activities in a fully remote environment.
- This role is responsible for performing prospective, concurrent, and retrospective medical reviews to determine medical necessity, appropriate level of care, intensity of service, and length of stay for healthcare services.
- The ideal candidate will have a strong clinical background, experience evaluating patient care needs, and the ability to collaborate with providers, facilities, and members to support quality healthcare outcomes.
Responsibilities
- Perform prospective, concurrent, and retrospective reviews of inpatient, outpatient, ambulatory, and ancillary healthcare services.
- Evaluate medical necessity, level of care, intensity of service, and appropriate length of stay.
- Review and assess appeal requests submitted by providers, facilities, and members.
- Apply clinical knowledge and evidence-based guidelines to utilization review decisions.
- Establish care plans and coordinate care across the healthcare continuum when appropriate.
- Conduct member outreach and assessments to support care coordination initiatives.
- Collaborate with physicians, healthcare providers, and interdisciplinary teams to facilitate quality patient care.
- Maintain accurate documentation and comply with organizational policies, regulatory requirements, and utilization management standards.
Required Qualifications
- Active, unrestricted Michigan Registered Nurse (RN) license.
- 2-4 years of clinical nursing experience.
- Demonstrated clinical knowledge related to patient care and healthcare delivery processes.
- Experience in one or more of the following areas:
- Acute patient care
- Discharge planning
- Case management
- Utilization review
- Strong analytical, problem-solving, and communication skills.
- Ability to work independently in a remote setting.
Preferred Qualifications
- Bachelor's degree in Nursing, Allied Health, Business, or a related field.
- Experience working with a health insurance plan or managed care organization.
- Certification in Case Management (CCM) or related certification.
- Prior experience in utilization management, precertification, or medical review environments.
Key Skills
- Utilization Review
- Medical Necessity Review
- Inpatient Precertification
- Care Coordination
- Case Management
- Appeals Review
- Clinical Assessment
- Healthcare Compliance
- Managed Care
- Documentation Review
- Patient Care Management
- Healthcare Operations
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