Clinical Reviewer

Clinical Utilization Review Nurse (RN) to assess medical necessity and quality of care through prospective, concurrent, and retrospective utilization management reviews. Apply InterQual criteria and organizational guidelines; consult with physician/practitioner when services do not meet medical necessity criteria; collaborate with internal teams and escalate as needed; provide clinical and utilization review subject matter expertise; respond to provider and stakeholder questions; conduct outreach to obtain additional clinical information; maintain accurate documentation and comply with regulatory and contract standards. Remote, full-time role supporting New Mexico contract requirements; requires RN licensure and at least 3 years of direct clinical experience.