Clinical Review Nurse, RN

MotivHealth Insurance Company

2d•Remote

About The Position

The Clinical Review Nurse (RN) supports the organization’s care management function by conducting clinical reviews, ensuring appropriate utilization of medical services, and maintaining compliance with regulatory and plan-specific guidelines. This role bridges clinical expertise with administrative processes to promote quality, cost-effective healthcare outcomes for members.

Requirements

A Current, unrestricted Registered Nurse (RN) license for Utah or compact license.
Minimum 3+ years of clinical experience(acute care, utilization review, or case management preferred).
Strong clinical assessment, critical thinking, and decision-making skills.
Excellent written and verbal communication skills.
Proficiency in EMR/UM software and Microsoft Office Suite.

Nice To Haves

Prior Utilization Management experience in a TPA or health plan setting strongly desired
Working knowledge of medical necessity criteria (MCG, InterQual) preferred.
Familiarity with ERISA, DOL, and state/federal regulations governing TPA operations a plus.

Responsibilities

Perform prospective, concurrent, and retrospective medical necessity reviews for inpatient, outpatient, and ancillary services.
Apply evidence-based guidelines (e.g., MCG, InterQual) to determine medical necessity and appropriateness of care.
Collaborate with physicians, providers, and other healthcare professionals regarding clinical determinations.
Ensure timely processing of pre-certification, prior authorization, and concurrent review requests.
Document clinical findings and review outcomes accurately within utilization management systems.
Identify potential quality-of-care issues and escalate appropriately.
Support case management teams in coordinating care for members with complex health needs.
Assist in transitions of care to reduce unnecessary readmissions.
Provide education to members and providers on coverage, benefits, and clinical guidelines.
Ensure adherence to regulatory requirements (state, federal, ERISA) and accreditation standards (URAC, NCQA, etc.).
Maintain confidentiality of Protected Health Information (PHI) in compliance with HIPAA.
Participate in audits, quality improvement initiatives, and staff training.