Clinical Review Nurse, RN

🕒 2 days ago

⛷️ Utah – Remote

⛷️ Utah – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 12%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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MotivHealth

WebsiteLinkedInAll Job Openings

51 - 200 employees

Founded 2015

🛡️ Insurance

🏥 Healthcare

💳 Fintech

Insurance • Healthcare • Fintech

MotivHealth is an innovative insurance company that focuses on creatively solving the high cost of healthcare. They aim to empower their members to become motivated healthcare consumers by providing a suite of integrated cost-saving solutions. Their offerings include SmartPay programs for price comparison in healthcare services and RX Assistance to reduce pharmacy costs. MotivHealth specializes in HSA-Qualified Health Plans and strives to help members grow their health savings and lower premiums, which leads to better health outcomes. Their unique approach significantly reduces annual premium increases when employers adopt smarter health plans.

📋 Description

• Perform prospective, concurrent, and retrospective medical necessity reviews for inpatient, outpatient, and ancillary services • Apply evidence-based guidelines (e.g., MCG, InterQual) to determine medical necessity and appropriateness of care • Collaborate with physicians, providers, and other healthcare professionals regarding clinical determinations • Ensure timely processing of pre-certification, prior authorization, and concurrent review requests • Document clinical findings and review outcomes accurately within utilization management systems • Identify potential quality-of-care issues and escalate appropriately • Support case management teams in coordinating care for members with complex health needs • Assist in transitions of care to reduce unnecessary readmissions • Provide education to members and providers on coverage, benefits, and clinical guidelines • Ensure adherence to regulatory requirements (state, federal, ERISA) and accreditation standards (URAC, NCQA, etc.) • Participate in audits, quality improvement initiatives, and staff training

🎯 Requirements

• A Current, unrestricted Registered Nurse (RN) license for Utah or compact license • Minimum 3+ years of clinical experience (acute care, utilization review, or case management preferred) • Prior Utilization Management experience in a TPA or health plan setting strongly desired • Working knowledge of medical necessity criteria (MCG, InterQual) preferred • Familiarity with ERISA, DOL, and state/federal regulations governing TPA operations a plus • Strong clinical assessment, critical thinking, and decision-making skills • Excellent written and verbal communication skills • Proficiency in EMR/UM software and Microsoft Office Suite • Maintain confidentiality of Protected Health Information (PHI) in compliance with HIPAA

🏖️ Benefits

• 5% annual bonus based on company profitability • Affordable health, vision, and dental insurance for you and your family • Company contributes up to $2,300 to Health Savings Account annually • Wellness program that contributes additional money towards your HSA • Automatic 3% contribution into retirement plan • Career development and growth opportunities • 15 days paid time off & 10 paid holidays per year