Job Description:

• Review and interpret medical records and clinical documentation to determine medical necessity and appropriateness of healthcare services
• Provide clinical review support for Treatment Authorization Requests (TARs) and other authorization activities
• Support medical review activities related to medical policy, claim adjudication, drug utilization review, and other healthcare program requirements
• Apply professional nursing principles, clinical judgment, medical policies, and established utilization guidelines when completing reviews
• Review documentation to determine whether requested services, procedures, supplies, and equipment meet coverage and clinical requirements
• Document review findings, decisions, and supporting clinical rationale accurately and timely
• Determine approvals within established guidelines or refer cases to physicians or other appropriate clinical professionals
• Apply knowledge of hospital routines, medical services, medical supplies, and appropriate clinical uses
• Collaborate with physicians, pharmacists, nurses, and other healthcare professionals
• Maintain current knowledge of clinical criteria, medical policies, procedures, and regulatory requirements
• Meet established quality, accuracy, productivity, and turnaround-time standards
• Work primarily from a home office supporting Medical Review Services for California healthcare programs
• Navigate multiple systems and applications to complete reviews and document findings

Requirements:

• Active and unrestricted Registered Nurse (RN) license to practice in the State of California, in good standing
• Minimum of two (2) years of professional nursing experience
• Possession of a Master’s Degree in Nursing may substitute for one (1) year of the required professional nursing experience
• Knowledge of professional nursing principles and techniques, hospital routines, and medical supplies and their uses
• Training and/or certification in wound and ostomy care preferred
• Strong clinical judgment and ability to interpret medical records and supporting clinical documentation
• Experience with medical review, utilization review, medical necessity review, prior authorization, Treatment Authorization Requests (TARs), or claims review preferred
• Strong written and verbal communication skills
• Ability to navigate multiple computer systems and applications
• Ability to maintain required professional licenses, certifications, and credentials in active, unrestricted, and good-standing status

Benefits:

• Flexible hours
• Work-life balance
• Continuous learning and career development
• Flexible vacation policy
• 401(k) employer match
• Comprehensive health benefits
• Educational assistance
• Leadership and technical development academies
• Ongoing training and support