Clinical Reviewer

Job Description Job Description We are partnering with a healthcare organization seeking experienced Nurse Reviewers for a long-term engagement with the possibility of full-time conversion. This role focuses on conducting medical record reviews across multiple service categories while ensuring compliance, medical necessity, and accuracy. Top 5 Ways You’ll Make an Impact Conduct medical record reviews using InterQual, MCG, or similar criteria to determine medical necessity. Perform utilization management across DME, acute care, inpatient services, imaging, genetic testing, and outpatient reviews. Use clinical judgment and regulatory knowledge to assess documentation against guidelines and contract requirements. Communicate with providers and internal teams to gather information, resolve questions, and support the review process. Meet productivity, turnaround times, and quality standards while managing daily workload and multiple review types. Note: Candidates must have experience in at least two of the following areas: Med/Surg, DME, Imaging, or Outpatient PT/OT/ST reviews. Job Summary As a Nurse Reviewer, you will evaluate clinical documentation to ensure services meet criteria and regulatory standards. You will conduct utilization reviews across diverse service categories, using critical thinking and established guidelines to make informed determinations. This role supports high-quality, compliant review processes and requires the ability to manage volume, maintain accuracy, and communicate effectively with providers and colleagues. Responsibilities Complete assigned review types accurately and within required timeframes. Analyze daily caseloads and adjust workflow as needed to meet department demands. Support quality assurance by participating in monitoring activities and addressing documentation or process concerns. Maintain current knowledge of review guidelines, clinical practices, and applicable criteria tools. Serve as a resource for review-related questions and support consistent application of guidelines. Act as a liaison to providers for documentation needs, clarification, and issue resolution. Foster professional communication with internal and external stakeholders to support smooth review operations. Participate in scheduled training sessions and updates related to review criteria and workflow processes. Crosstrain on additional review categories to support staffing flexibility. Adhere to all HIPAA, privacy, and security standards. Required Qualifications Active, unrestricted RN or LPN license in Colorado or a Compact state. Diploma, certificate, or degree in Nursing. Experience in at least two of the following review areas: Med/Surg DME Imaging Outpatient PT/OT/ST 3+ years of clinical experience in acute care, behavioral health, or medical-surgical settings. 2+ years of Utilization Review/Management (UR/UM) or Prior Authorization experience. Experience reviewing medical necessity for services including DME, acute inpatient care, outpatient services, imaging, genetic testing, and related categories. At least 1 year using InterQual, MCG, or other nationally recognized clinical criteria. Ability to navigate multiple systems, platforms, and databases efficiently. Strong communication, critical thinking, and clinical assessment skills. Strong organizational skills with the ability to prioritize effectively. Preferred Qualifications Associate, Diploma, or Bachelor’s degree in Nursing or a related field. Familiarity with NCQA and/or URAC standards. Ability to work collaboratively in a team-focused environment. Proficiency in Microsoft Office applications. Strong time management and ability to meet deadlines. Ability to maintain confidentiality and uphold HIPAA standards. #J-18808-Ljbffr