Job Description

We are looking for a knowledgeable and detail-driven PH Registered Nurse to join our growing clinical review team. This role is ideal for nurses who are experienced in applying clinical guidelines such as InterQual , MCG , NCD , and LCD , and who are comfortable evaluating the medical necessity of various healthcare services.

What You’ll Do

  • Utilize InterQual, MCG, NCD, and LCD criteria to review inpatient and outpatient cases.
  • Assess patient documentation to determine the appropriateness and necessity of recommended services.
  • Work alongside medical directors and interdisciplinary teams to address complex clinical scenarios.
  • Ensure all reviews meet payer, regulatory, and internal compliance standards.
  • Maintain accurate, organized, and complete documentation for all case evaluations.
  • Support internal quality checks, audits, and process improvement initiatives.
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