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. This is a remote role open to candidates residing in Utah, Texas, or Arizona.
HOW YOU'LL MAKE AN IMPACT: Clinical Review & Case Management
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.
Utilization Management:
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.
Member Advocacy & Coordination:
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.
Compliance & Quality:
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.
WHAT YOU BRING:
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).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. Strong clinical assessment, critical thinking, and decision-making skills. Excellent written and verbal communication skills. Proficiency in EMR/UM software and Microsoft Office Suite. HOW WE SUPPORT YOU:Affordable health, vision, and dental insurance for you and your family Company contributes up to $2,300 to Health Savings Account annually Wellness program that contributes additional money towards your HSAAutomatic 3% contribution into retirement plan Career development and growth opportunities15 days paid time off & 10 paid holidays per year MotivHealth is a dynamic and mission-driven health insurance company dedicated to disrupting the status quo by making healthcare simpler and more affordable for our members. We believe in empowering our members to take control of their health and financial well-being. Our innovative approach requires a team of passionate, talented individuals who aren't afraid to challenge conventional thinking and build solutions that truly make a difference. If you're looking to contribute your skills to a company that values innovation and positive impact, MotivHealth is the place for you.
