Registered Nurse-Review Analyst

This role is responsible for performing prospective, concurrent, and retrospective medical reviews to determine medical necessity, appropriate level of care, intensity of service, and length of stay for healthcare services. The ideal candidate will have a strong clinical background, experience evaluating patient care needs, and the ability to collaborate with providers, facilities, and members to support quality healthcare outcomes.

Job Title: Registered Nurse Review Analyst
Location: Remote
Duration: 12-Month Contract
Department: MA Inpatient Precertification
Pay Rate: $30-$40/hour

Work Arrangement

• Fully Remote
• No onsite requirements anticipated during the assignment.

Position Overview

• We are seeking a Registered Nurse Review Analyst to support inpatient precertification and utilization management activities in a fully remote environment.
• This role is responsible for performing prospective, concurrent, and retrospective medical reviews to determine medical necessity, appropriate level of care, intensity of service, and length of stay for healthcare services.
• The ideal candidate will have a strong clinical background, experience evaluating patient care needs, and the ability to collaborate with providers, facilities, and members to support quality healthcare outcomes.

Responsibilities

• Perform prospective, concurrent, and retrospective reviews of inpatient, outpatient, ambulatory, and ancillary healthcare services.
• Evaluate medical necessity, level of care, intensity of service, and appropriate length of stay.
• Review and assess appeal requests submitted by providers, facilities, and members.
• Apply clinical knowledge and evidence-based guidelines to utilization review decisions.
• Establish care plans and coordinate care across the healthcare continuum when appropriate.
• Conduct member outreach and assessments to support care coordination initiatives.
• Collaborate with physicians, healthcare providers, and interdisciplinary teams to facilitate quality patient care.
• Maintain accurate documentation and comply with organizational policies, regulatory requirements, and utilization management standards.

Required Qualifications

• Active, unrestricted Michigan Registered Nurse (RN) license.
• 2-4 years of clinical nursing experience.
• Demonstrated clinical knowledge related to patient care and healthcare delivery processes.
• Experience in one or more of the following areas:
  • Acute patient care
  • Discharge planning
  • Case management
  • Utilization review
• Strong analytical, problem-solving, and communication skills.
• Ability to work independently in a remote setting.

Preferred Qualifications

• Bachelor's degree in Nursing, Allied Health, Business, or a related field.
• Experience working with a health insurance plan or managed care organization.
• Certification in Case Management (CCM) or related certification.
• Prior experience in utilization management, precertification, or medical review environments.

Key Skills

• Utilization Review
• Medical Necessity Review
• Inpatient Precertification
• Care Coordination
• Case Management
• Appeals Review
• Clinical Assessment
• Healthcare Compliance
• Managed Care
• Documentation Review
• Patient Care Management
• Healthcare Operations

#LI-MC1

#INDEPI

#INDPRO