Medical Necessity Evaluator

About the Role

We are seeking a skilled Nurse to join our . In this role, you will be responsible for reviewing clinical information provided by facilities to determine medical necessity when our members admit. You will also be involved in discharge planning and transfers as needed for higher levels of care or out-of-network admissions.

The ideal candidate will have strong communication and computer navigation skills, as well as a current California RN License. A Bachelor's degree in Nursing or advanced degree is preferred. Key responsibilities include:

1. Reviewing clinical information provided by facilities to determine medical necessity when our members admit.
2. Being involved in discharge planning and transfers as needed for higher levels of care or out-of-network admissions.
3. Ensuring that all case work meets quality and productivity metrics.
4. Maintaining a HIPAA-compliant workspace for telework environment.