State Licensed Clinical Reviewer

A company is looking for a Clinical Reviewer to perform Utilization Management and review clinical information for service requests.

Key Responsibilities

Evaluate referral appropriateness for services and determine medical necessity

Request additional clinical information and interact with the Medical Director as needed

Ensure timely case review and maintain knowledge of services and guidelines

Required Qualifications

Associate's Degree or Diploma in Nursing / Practical Nursing

Registered Nurse / LPN / LVN with active licensure in the state(s) of practice

1-2 years prior authorization experience for Medicare or Medicare Advantage Home Health

Minimum of 2 years in a clinical setting

Knowledge of Medicare PDGM and experience with Interqual is desired