New 
Care Review Clinician I (71822)
 Professional Management Enterprises | |
 United States, Texas, Houston | |
 Jun 11, 2025 | |
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Care Review Clinician Iwork with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and other utilization management activities aimed at providing members'ultimate care.MUST be licensed RN or LPN inTexas or Compact. This position is FULLY REMOTE. Schedule M-F 8am-5pm EST or CST. Day to Day Responsibilities: Review Prior auth/Inpatient/Skilled Nursing requests for medical necessity using State/Policy or MCG criteria. KNOWLEDGE/SKILLS/ABILITIES * Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review * Analyzes clinical service requests from members or providers against evidence based clinical guidelines. * Identifies appropriate benefits and eligibility for requested treatments and/or procedures. * Conducts prior authorization reviews to determine financial responsibility for members. * Processes requests within required timelines. * Refers appropriate prior authorization requests to Medical Directors. * Requests additional information from members or providers in consistent and efficient manner. * Makes appropriate referrals to other clinical programs. * Collaborates with multidisciplinary teams to promote Care Model * Adheres to UM policies and procedures. Must Have Skills: at least 1 year UM experience in a HP setting RN or LPN The ability to work remote in a high pace/high demand environment. The ability to complete 15-20 authorization in a day Previous experience using QNXT/UMK2/PEGA preferred MCG Experience preferred. Required Years of Experience: 1 Required Licensure / Education: RN or LPN | |