Nurse Clinical Reviewer
Job description
Nurse performs utilization management functions for selected services to ensure the correct application of contract and policy benefits for assigned lines of business.
Experience: 3-5 years’ utilization management, clinical review experience
Education: Associates Degree in Nursing or Bachelors Degree in Nursing
Licenses/Certifications: Must hold one of the following:
- Valid unrestricted Registered Nursing License
What a day of a Nurse Clinical Reviewer would look like:
- Make clinical decisions using approved and accepted plan policies and criteria.
- Determine eligibility and benefit coverage according to member and provider contracts.
- Identify appropriate members for medical or behavioral health case management.
- Respond to requests for authorization of medications or inpatient procedures and services.
- Document and reports potential quality of care or service issues to leadership.
- Perform peer to peer audits to assist with consistency of application of business workflows.
- May provide review according to established criteria for procedural authorization.
- Perform other duties and responsibilities as assigned.
Additional skills that we are looking for:
- High degree verbal and written communication
- Independent and critical thinking
- Handle multiple projects simultaneously
- Work well in a team environment
Additional detail: Hybrid work schedule for those in the local area. Open to out of state remote workers.
Time zones work hours: Mountain Time Zone
Duration of this role will be 6 months to a year.
Dexian is a leading provider of staffing, IT, and workforce solutions with over 12,000 employees and 70 locations worldwide. As one of the largest IT staffing companies and the 2nd largest minority-owned staffing company in the U.S., Dexian was formed in 2023 through the merger of DISYS and Signature Consultants. Combining the best elements of its core companies, Dexian’s platform connects talent, technology, and organizations to produce game-changing results that help everyone achieve their ambitions and goals.
Dexian’s brands include Dexian DISYS, Dexian Signature Consultants, Dexian Government Solutions, Dexian Talent Development and Dexian IT Solutions. Visit https://dexian.com/ to learn more.
Dexian is an Equal Opportunity Employer that recruits and hires qualified candidates without regard to race, religion, sex, sexual orientation, gender identity, age, national origin, ancestry, citizenship, disability, or veteran status.
