Location
United States
Posted
June 14, 2026
Commute
Local Area
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Job Description
Our client, is a Health Insurance company, is looking for a Nurse RN 3 for their Remote location. Responsibilities:
+ Perform prospective, concurrent, and retrospective utilization reviews and first level determination approvals for members using client and CMS evidenced based guidelines, policies and nationally recognized clinal criteria for the client Medicare line of business.
+ Ensure discharge planning at appropriate levels of care for the members’ needs and acuity.
+ Durable medical equipment, and post service needs to ensure quality and cost-appropriate DC planning.
+ Prepare and present cases to Medical Director for oversight/necessity determination and communicate determinations to providers and members to comply with state, federal and accreditation requirements.
+ Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards.
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+ Perform prospective, concurrent, and retrospective utilization reviews and first level determination approvals for members using client and CMS evidenced based guidelines, policies and nationally recognized clinal criteria for the client Medicare line of business.
+ Ensure discharge planning at appropriate levels of care for the members’ needs and acuity.
+ Durable medical equipment, and post service needs to ensure quality and cost-appropriate DC planning.
+ Prepare and present cases to Medical Director for oversight/necessity determination and communicate determinations to providers and members to comply with state, federal and accreditation requirements.
+ Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards.
<...