This role involves performing RN duties to ensure the appropriate level of care and planning for care transitions, assessing patient clinical needs against established guidelines for medical appropriateness of inpatient stays. Responsibilities also include serving as a mentor/trainer to new RNs and acting as a subject matter expert for various projects and committees.

The Professional Review Analyst analyzes medical services and billing across various claim types to evaluate the accuracy of charges and the medical necessity of care provided. This is a remote role. Candidate must be located in the greater Charlotte, North Carolina Region and ab...

The Nurse Reviewer I conducts preauthorization, out of network, and appropriateness of treatment reviews for diagnostic imaging services by utilizing appropriate policies and clinical guidelines. This role involves collaborating with healthcare providers and members to ensure the most appropriate and effective use of imaging while learning to conduct medical necessity clinical screenings.

The specialist will conduct utilization reviews for admissions and continued stays using approved clinical criteria to determine medical necessity, collaborating with the interdisciplinary team and financial clearance center regarding resource utilization and billing issues. Key functions also involve managing denial processes, coordinating peer-to-peer reviews, and accurately recording data for statistical entry and workflow queues.