Clinical Review Rn Jobs

Clinical Review RN, Oncology AI Review Position Summary Natera is seeking an experienced Oncology Registered Nurse (RN) to support the clinical review and validation of AI-driven workflows that power Signatera reimbursement and coverage operations. This role will serve as a clinical subject matter expert responsible for reviewing complex oncology cases, auditing AI-generated clinical classifications, interpreting payer policy requirements, and providing feedback that improves the performance of Natera's clinical AI systems. The ideal candidate combines strong oncology expertise with a curiosity for technology and process improvement. This position is highly collaborative and will work closely with Clinical Operations, Revenue Cycle Management, Product, Engineering, and Data Science teams to improve the accuracy, scalability, and effectiveness of AI-assisted clinical review processes. Primary Responsibilities Clinical Case Review & Escalations Review oncology patient records to determine whether cases meet clinical and payer policy requirements. Serve as an escalation point for complex cases that cannot be accurately classified by AI workflows. Analyze challenging clinical scenarios, including patients with multiple cancer diagnoses, complex treatment histories, and ambiguous documentation. Document findings and recommendations within internal systems including Salesforce, LIMS, and other workflow tools. Ensure accuracy and consistency of clinical review outcomes. AI Audit

Opportunity Overview: The Clinical Review & Correspondence RN plays a critical role in supporting utilization management operations by conducting medical necessity reviews, preparing clear and compliant clinical determinations, and ensuring accurate member and provider communications. In collaboration with Medical Directors and cross-functional partners, this role ensures that clinical decisions are evidence-based, align with regulatory and accreditation standards, and are communicated effectively and timely. Through precise clinical review and documentation, you will help support high-quality care, regulatory compliance, and improved member outcomes. What you’ll do: Consult with Medical Directors on clinical determinations, medical necessity decisions, and related clinical correspondence Prepare clear, accurate, and compliant member and provider communications in alignment with regulatory and organizational requirements Understand regulatory requirements governing utilization management decisions and ensure appropriate application to clinical determinations and communications Understand when and why member and provider notifications are required, including regulatory and clinical triggers for written communication Support verbal notification workflows when timely communication of clinical determinations is required Document clinical information completely, accurately, and in a timely manner Consistently meet or exceed productivity, quality, and turnaround time expe

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Utilization Management Nurse Consultant (RN) Remote | Concurrent Review | Utilization Management Are you an experienced RN with utilization management or prior authorization experience looking to make an impact beyond bedside care? Join our team and help ensure members receive timely, appropriate, and cost-effective healthcare services through evidence-based clinical review and decision-making. What You'll Do Review authorization requests across a broad range of medical specialties Evaluate medical necessity using clinical records, evidence-based guidelines, and benefit plan requirements Apply InterQual, MCG, or similar clinical criteria to support authorization determinations Collaborate with providers, care managers, medical directors, and interdisciplinary teams to facilitate quality care Ensure compliance w

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Registered Nurse (RN) – Utilization Management Remote | Work from Home | Eastern Time Zone Preferred Are you an experienced RN looking to leverage your clinical expertise in a non-bedside role? Join our Utilization Management team and help ensure members receive the right care at the right time through evidence-based clinical review, care coordination, and healthcare advocacy. What You'll Do Review clinical information and apply established guidelines, policies, and clinical judgment to support coverage determinations Assess, coordinate, monitor, and evaluate healthcare services and benefits across the continuum of care Collaborate with providers and care teams to facilitate appropriate treatment and care planning Identify opportunities to improve quality of care, member outcomes, and healthcare utilization Connect members with additional progr

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Registered Nurse (RN) – Utilization Management Remote | Work from Home | Eastern Time Zone Preferred Are you an experienced RN looking to leverage your clinical expertise in a non-bedside role? Join our Utilization Management team and help ensure members receive the right care at the right time through evidence-based clinical review, care coordination, and healthcare advocacy. What You'll Do Review clinical information and apply established guidelines, policies, and clinical judgment to support coverage determinations Assess, coordinate, monitor, and evaluate healthcare services and benefits across the continuum of care Collaborate with providers and care teams to facilitate appropriate treatment and care planning Identify opportunities to improve quality of care, member outcomes, and healthcare utilization Connect members with additional progr

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Utilization Management Nurse Consultant Clinical Precertification RN (Medicare) Remote | Full-Time | Weekday Schedule Are you a Registered Nurse ready to make an impact beyond the bedside? Join our team and use your clinical expertise to ensure members receive the right care at the right time. What You’ll Do · Review clinical cases and make coverage determinations using evidence-based guidelines · Collaborate with providers and care teams to coordinate appropriate treatment · Apply clinical judgment to support utilization and benefit management decisions · Identify opportunities to improve care quality and member outcomes · Serve as a clinical resource across internal and external stakeholders What You Bring - REQUIRED · Active, unrestricted RN license in the state of residence. · 3+ years of RN

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Registered Nurse (RN) – Utilization Management Join a dynamic healthcare team and make an impact on patient care from wherever you work. We are seeking an experienced Registered Nurse (RN) to support our 24/7 Utilization Management operations. In this role, you will use your clinical expertise to review cases, assess medical necessity, coordinate care, and help ensure members receive appropriate, high-quality healthcare services. What You'll Do Review clinical information and apply evidence-based criteria to support coverage determinations and care recommendations. Collaborate with providers, care teams, and internal partners to coordinate treatment and services. Identify opportunities to improve healthcare quality, outcomes, and benefit utilization. Refer members to appropriate programs and services that support their overall health needs.</

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Utilization Management Nurse Consultant (RN) Make a meaningful impact on patient care from wherever you are. We are seeking an experienced Registered Nurse (RN) to join our Utilization Management team. In this role, you will use your clinical expertise to review healthcare services, support appropriate care decisions, collaborate with providers, and help members navigate their healthcare journey. What You'll Do Review clinical information and apply evidence-based criteria to make coverage recommendations. Collaborate with healthcare providers and internal teams to support quality patient outcomes. Identify opportunities for care coordination and member support programs. Promote effective healthcare utilization and contribute to high-quality service delivery. Manage multiple systems and priorities in a fast-paced, team-orien

Job Title: Virtual Care Nurses (RN, LPN/LVN) Part-Time Location: 100% Remote - United States Employment Type: Part-Time W2 Hourly Compensation: RN $40 p/hour; LPN/LVN $25 p/hour Compact Multi-State Licensure Required About CareTalk Health CareTalk Health is a fully remote, nationwide virtual medical practice. We partner with Medicare Advantage plans to deliver Annual Wellness Visits and close care gaps, reaching members wherever they are. We believe virtual care isn't a compromise — it's care delivered the way patients actually want it. Our job is to make that experience simple, reliable, and human. About the Role CareTalk Health is seeking experienced and highly organized Nurses to join our virtual care team. This fully remote role resides in our Virtual Clinic environment and is focused on supporting patients during their Annual Wellness Visit (AWV). Responsibilities include chart preparation, and supporting providers in delivering comprehensive, compliant, patient-centered care. This role requires strong clinical judgment, excellent documentation skills, comfort with telehealth workflows, and the ability to work independently across multiple platforms. Schedule Minimum 20 hours per week Between the hours of Monday-Friday 10am-4pm EST and one Saturday a month between the hours of 10am-4pm EST Rotating Holidays What You’ll Do Annual Wellness Visit (AWV) Chart Preparation · Prepare compreh

Job Title: Virtual Care Nurses (RN, LPN/LVN) Location: 100% Remote - United States Employment Type: Full-Time W2 Hourly Compensation: RN $40 p/hour; LPN/LVN $25 p/hour Compact Multi-State Licensure Required About CareTalk Health CareTalk Health is a fully remote, nationwide virtual medical practice. We partner with Medicare Advantage plans to deliver Annual Wellness Visits and close care gaps, reaching members wherever they are. We believe virtual care isn't a compromise — it's care delivered the way patients actually want it. Our job is to make that experience simple, reliable, and human. About the Role CareTalk Health is seeking experienced and highly organized Nurses to join our virtual care team. This fully remote role resides in our Virtual Clinic environment and is focused on supporting patients during their Annual Wellness Visit (AWV). Responsibilities include chart preparation, and supporting providers in delivering comprehensive, compliant, patient-centered care. This role requires strong clinical judgment, excellent documentation skills, comfort with telehealth workflows, and the ability to work independently across multiple platforms. Schedule 40 hours per week Full-time hours: M-F, 9:30 AM - 6:00 PM EST, and one Saturday a month 10:00 AM - 4:00 PM EST Rotating holidays What You’ll Do Annual Wellness Visit (AWV) Chart Preparation · Prepare comprehensive AWV charts to support provider ef

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Utilization Management Nurse Consultant (RN) – Concurrent Review Remote | Acute Inpatient Utilization Management | RN Opportunity Are you an experienced RN with a background in acute care and utilization management? Join our team and play a vital role in ensuring members receive appropriate, high-quality, and cost-effective inpatient care through concurrent review and care coordination. What You'll Do Perform concurrent reviews for acute inpatient admissions and continued hospital stays Evaluate medical necessity, severity of illness, intensity of service, and level of care using evidence-based clinical criteria Collaborate with hospitals, physicians, care managers, and discharge planners to support appropriate treatment and timely transitions of care Review clinical documentation and apply health plan benefits and regulatory requirements to authorization

Opportunity Overview: The RN Reviewer position is a crucial role in our organization — in this role you are responsible for performing a full range of activities that will positively impact the organization and contribute to guiding the strategic operations for the company. As an RN Reviewer, you will perform prospective review (prior authorization) admission, concurrent, and retrospective reviews according to established criteria and protocols to determine the medical appropriateness of the clinical requests from providers. You will work closely with Medical Directors and other Cohere Health staff to ensure appropriate cost-effective care by applying your clinical knowledge and critical thinking skills to assess the medical necessity of inpatient admissions, outpatient services and procedures, and provider out of network requests. You will be required to review Commercial, Medicare, and Medicaid lines of business. You will need to be an agile and comprehensive thinker and planner and be able to work in an environment that is in flux. This position offers the ability to make a substantive mark in simplifying the way healthcare is delivered and contributes to an up and coming company with exponential growth opportunity. What you'll do: Review medical necessity for inpatient, concurrent, prior auth, and retrospective cases to ensure appropriate, high-quality care Collaborate with Medical Directors and providers to align on clinical decisions Document reviews accurat

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary: The Case Manager RN role is telework and must be located in North Carolina. Normal Working Hours: Monday through Friday 9:00am – 5:30pm EST. Occasional evening, and holiday shifts per the needs of the team. 0-10% travel possible including but not limited to travel to the High Point office for customer meetings if you reside within 30 miles. The RN Case Manager is responsible for telephonically assessing, planning, implementing, and coordinating all case management activities with members to evaluate the medical needs of the member to facilitate the member’s overall wellness. RN Case Manager: Develops a proactive course of action to address issues presented to enhance the short and long-term outcomes as well as opportunities to enhance a member’s overall wellness through integration. Through the use of clinic

RN Case Manager Location : Onsite in Dubuque, IA. We are seeking a compassionate and detail-oriented RN Case Manager to join our team. This role is responsible for delivering comprehensive case management services across the continuum of care. The RN Case Manager will assess, plan, implement, coordinate, monitor, and evaluate care for assigned consumers, ensuring quality outcomes and cost-effective treatment. Key Responsibilities: Provide telephonic case management and utilization review for assigned consumers. Develop, implement, and monitor individualized care plans to ensure quality and cost-effective outcomes. Collaborate with healthcare providers, payors, and internal teams to coordinate care. Serve as a liaison between consumers and benefit administrators, ensuring clear communication and support. Track and report case outcomes, including cost savings and quality improvements. Qualifications: Education: RN licensure in the State of Iowa required. BSN or higher preferred. Experience: Minimum 2 years of clinical practice. Case management or utilization review experience strongly preferred. Skills: Strong communication, problem-solving, and computer skills. Ability to work independently. Full-Time Benefits - Most benefits start day 1 Medical, Dental, Vision Insurance Flex Spending or HSA 401(k) with company match Profit-Sharing/Defined Contribution (1-year waiting period) PTO/Paid Holidays Company-paid ST and LT Disability Maternit

Bilingual RN Case Manager Location : Remote. We are seeking a compassionate and detail-oriented Bilingual RN Case Manager to join our team. This role is responsible for delivering comprehensive case management services across the continuum of care. The RN Case Manager will assess, plan, implement, coordinate, monitor, and evaluate care for assigned consumers, ensuring quality outcomes and cost-effective treatment. Key Responsibilities: Provide telephonic case management and utilization review for assigned consumers. Develop, implement, and monitor individualized care plans to ensure quality and cost-effective outcomes. Collaborate with healthcare providers, payors, and internal teams to coordinate care. Serve as a liaison between consumers and benefit administrators, ensuring clear communication and support. Track and report case outcomes, including cost savings and quality improvements. Qualifications: Bilingual: the ability to speak Spanish Education: RN licensure in the State of Iowa required. BSN or higher preferred. Experience: Minimum 2 years of clinical practice. Case management or utilization review experience strongly preferred. Skills: Strong communication, problem-solving, and computer skills. Ability to work independently. Full-Time Benefits - Most benefits start day 1 Medical, Dental, Vision Insurance Flex Spending or HSA 401(k) with company match Profit-Sharing/Defined Contribution (1-year waiting period) PTO/Paid Holidays Com