Clinical Review Nurse
Job Description
Clinical Review Nurse
Location: Alameda, CA
Pay: $66.00/hour
Schedule: Full-Time, Monday–Friday, 8:00 AM–5:00 PM
License Required: Active California RN License
Hiring Clinical Review Nurses in Alameda, CA
We are hiring a Clinical Review Nurse in Alameda, California for a full-time opportunity focused on appeals, grievances, medical necessity review, utilization review, and managed care clinical case evaluation. This role is ideal for an experienced Registered Nurse with strong knowledge of clinical documentation review, regulatory turnaround requirements, and health plan or managed care processes.
The Clinical Review Nurse will review complex clinical cases, assess medical records, apply established guidelines, and prepare recommendations related to appeals, grievances, and provider disputes. This role also supports timely case resolution, quality review, and written clinical determinations.
Clinical Review Nurse Responsibilities
- Review and investigate member and provider appeals and grievances
- Evaluate prospective, inpatient, and retrospective medical records for medical necessity
- Apply clinical guidelines, internal policies, and benefit criteria to case review
- Summarize clinical findings for leadership or physician review
- Prepare recommendations to uphold or overturn determinations
- Ensure cases are resolved within required regulatory timeframes
- Document case activity accurately in tracking systems
- Draft written correspondence for providers, members, and regulatory entities
- Identify quality of care concerns and escalate appropriately
- Serve as a subject matter resource for appeals, grievances, disputes, and quality issues
- Support reporting, case analysis, and additional clinical review projects as needed
Clinical Review Nurse Requirements
- Active and unrestricted California Registered Nurse license
- At least 3 years of acute care clinical experience
- At least 2 years of appeals and grievances experience
- Bachelor’s degree preferred
- Experience in utilization management or quality management preferred
- Experience using clinical review guidelines preferred
- Knowledge of MCG, managed care, and NCQA preferred
- Strong clinical judgment and critical thinking skills
- Strong written communication and documentation skills
- Ability to manage complex clinical cases and meet deadlines
Preferred Background for a Clinical Review Nurse
Candidates with experience in the following areas are strongly encouraged to apply:
- Clinical Review
- Appeals and Grievances
- Utilization Review
- Managed Care
- Quality Management
- Case Review
- Medical Necessity Review
- Regulatory and compliance-driven clinical review
Top Skills for This Clinical Review Nurse Role
- Clinical review
- Appeals and grievances
- Medical necessity review
- Utilization management
- Managed care
- Quality management
- Case investigation
- Clinical documentation review
- Regulatory compliance
- MCG guidelines
- NCQA
- Written determinations
Apply for Clinical Review Nurse Jobs in Alameda, CA
If you are a California RN with experience in appeals, grievances, utilization review, managed care, or quality-based clinical review, this Clinical Review Nurse opportunity may be an excellent fit.