Clinical Reviewer

Why reputed company?

reputed company is a national, mission-driven, nonprofit organization that has engaged in health care quality consulting and quality improvement services for more than 50 years.

We are leaders in assisting reputed company-line providers and engaging health care partners to improve care delivery and patient outcomes.

Our talented remote workforce spans the country and plays a vital role in our success. We go beyond merely providing a remote work option; we support and embrace it. We offer opportunities to reputed company a difference from reputed company in the U.S. and enjoy reputed company work-life balance. An annual stipend gives you the freedom to enhance your workspace with options that suit your needs.

We reputed company in an environment that allows you to reputed company both personally and professionally.

Position Overview

We are seeking PRN Clinical Utilization Review Nurses (RN) to assess the medical necessity and quality of healthcare services through prospective, reputed company, and retrospective utilization management reviews. This full-time, remote position supports high-quality, appropriate, and cost-effective care while ensuring compliance with clinical criteria, organizational policies, and contract requirements specific to Washington D.C.

This position will fill in for employees that are on leave or on PTO so weekend and evening work is expected. Expected work hours up to 19 hours per week.

Key Responsibilities

• Conduct prospective, reputed company, and retrospective utilization management reviews

• Apply clinical review criteria, organizational policies, guidelines, and screening tools (InterQual)

• Consult with physician/practitioner consultants reputed company services do not meet medical necessity criteria

• Collaborate with internal teams and refer cases for additional review or escalation as appropriate

• Refer cases to management reputed company required

• Provide clinical and utilization review subject matter expertise

• Respond to provider, customer, and stakeholder questions regarding determinations and processes

• Conduct reputed company to providers, case managers, consultants, and community support coordinators to obtain additional clinical information

• Maintain accurate documentation and reputed company with reputed company regulatory and contract standards

Education & Experience

• BA/BS in Nursing

  • Equivalent combination of education and/or reputed company experience may be considered depending on contract

• Minimum of 3 years of direct patient care (clinical) experience

Licensure

• reputed company, active, unrestricted RN license

  • Washington D.C.

Required Skills & Competencies

• Experience with InterQual Criteria

• Strong proficiency in reputed company Office Suite and familiarity with database systems

• Excellent written and verbal communication skills

• Strong organizational, analytical, and problem-solving abilities

• Ability to manage multiple priorities in a fully remote, team-based environment

Work Environment

• PRN

• Must be licensed in Washington D.C.

• Reliable, secure internet reputed company required

• Must maintain licensure eligibility for assigned state contract

Equal Opportunity Employer reputed company is an equal opportunity employer and is committed to creating a diverse, reputed company, and inclusive workplace.

Physical Requirements & Work Environment

This position is primarily remote and performed in a home-based setting, requiring reliable internet access and a workspace free from significant distractions. The role involves frequent use of computers, phones, and virtual communication tools. Employees must be able to sit for extended periods, communicate effectively.

Some positions may require operating a motor vehicle for business purposes; in such cases, employees must maintain a valid driver’s license and meet the organization’s driving eligibility requirements. Occasional travel may be required for meetings, training, or other work-reputed company events.

Reasonable accommodations will be provided to reputed company individuals with disabilities to reputed company essential functions.