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Clinical Review Rn Jobs in Virginia (NOW HIRING)

GQR Global Markets

RN Case Manager

Charlottesville, VA · On-site

$1.8K - $1.9K/wk

Contract - W2 Case Management/Utilization Review Registered Nurse (RN) Job Location ... eligible clinicians based on nationally published GSA rates. Actual weekly pay and per diems may ...

GQR

RN - Case Manager

Charlottesville, VA · On-site

$1.8K - $1.9K/wk

Contract - W2 Case Management/Utilization Review Registered Nurse (RN) Job Location ... eligible clinicians based on nationally published GSA rates. Actual weekly pay and per diems may ...

GQR Healthcare

Travel Case Manager RN

Charlottesville, VA · On-site

$1.8K - $1.9K/wk

Travel Contract - W2 Case Management/Utilization Review Registered Nurse (RN) Job Location ... eligible clinicians based on nationally published GSA rates. Actual weekly pay and per diems may ...

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Clinical Review Rn information

What is a clinical review RN?

Clinical Review RNs, or Clinical Review Registered Nurses, are licensed nurses who evaluate medical records, treatment plans, and health care documentation to ensure that patient care meets established standards and guidelines. They play a critical role in reviewing the medical necessity, appropriateness, and efficiency of healthcare services provided to patients. Clinical Review RNs often work for insurance companies, hospitals, or healthcare organizations to help with utilization management, case review, and quality assurance. Their expertise helps improve patient outcomes and manage healthcare costs by ensuring the right care is delivered at the right time.

What skills and qualifications are needed to thrive as a clinical review RN?

To thrive as a Clinical Review RN, you need a robust clinical nursing background, strong assessment skills, and an active RN license, often with experience in case management or utilization review. Familiarity with utilization management software, electronic health records, and knowledge of insurance regulations or CMS guidelines is typically required. Excellent communication, critical thinking, and attention to detail help set outstanding Clinical Review RNs apart. These skills ensure accurate clinical evaluations, compliance with regulations, and effective coordination between patients, providers, and payers.

How does a clinical review RN collaborate with other healthcare professionals during the patient care review process?

A Clinical Review RN regularly works with physicians, case managers, social workers, and insurance representatives to assess the medical necessity and appropriateness of patient care plans. They participate in interdisciplinary meetings, provide clinical insights, and help ensure that care decisions align with policies and regulations. This collaboration is key to streamlining the review process, minimizing delays in patient care, and supporting optimal outcomes for both patients and the healthcare organization.

What is the difference between Clinical Review Rn vs Medical Reviewer?

AspectClinical Review RnMedical Reviewer
CredentialsRegistered Nurse (RN) license, clinical experienceMedical degree (MD or DO), specialized training
Work EnvironmentHealthcare facilities, insurance companies, telehealthHospitals, insurance companies, consulting firms
Employer & Industry UsageInsurance, healthcare providers, government agenciesInsurance, legal, healthcare consulting
Primary FocusAssessing medical records, determining coverage eligibilityEvaluating medical cases, providing expert opinions

While both roles involve reviewing medical information, Clinical Review Rns primarily assess insurance claims and medical records as registered nurses, whereas Medical Reviewers are typically physicians with advanced medical training who evaluate complex cases and provide expert opinions. Understanding these differences helps in choosing the right career path or job search focus.

How to become a clinical review RN?

To become a clinical review RN, you typically need to earn a Bachelor of Science in Nursing (BSN) or an associate degree in nursing, pass the NCLEX-RN exam to obtain licensure, and gain clinical experience in healthcare settings. Additional certifications in case management or utilization review can enhance qualifications for this role.

What does a clinical review RN do?

A clinical review RN evaluates medical records, treatment plans, and patient data to determine coverage, appropriateness, and compliance with healthcare policies. They often work for insurance companies or healthcare organizations, requiring strong clinical knowledge, attention to detail, and certification such as a registered nurse license. Their assessments help ensure proper patient care and cost-effective treatment decisions.
Clinical Review Rn jobs near you
Infographic showing various Clinical Review Rn job openings in Virginia as of August 2026, with employment types broken down into 1% As Needed, 76% Full Time, 20% Part Time, 2% Contract, and 1% Nights. Highlights an 89% Physical, 3% Hybrid, and 8% Remote job distribution.

Utilization Review Registered Nurse

Richmond, VA • On-site

3M HEALTHCARE
10K+ employees
Learn more about 3M HEALTHCAREexternal

$100 - $125/hr

Other

Posted 7 days ago

Job description

Job Overview

The Utilization Review RN is responsible for utilization management and review for prospective, concurrent, or retrospective cases. The role functions within a multidisciplinary team including physicians, social workers, discharge planning assistants, and payers, evaluating medical appropriateness of inpatient and outpatient services per guidelines and benefit determination.

Responsibilities
  • Conduct prospective, concurrent, and retrospective utilization reviews for inpatient services, observation services, and specific outpatient service requests.
  • Determine medical appropriateness of inpatient and outpatient services by evaluating medical guidelines and benefit determinations.
  • Collaborate with attending and consulting physicians to facilitate efficient transitions during hospitalization.
  • Work with the multidisciplinary team to coordinate care and ensure reimbursement aligns with payer contracts and efficient resource use.
  • Use medical necessity criteria to assess level and setting of care, assist in denial and appeals, evaluate quality, and identify potential risk management issues.
  • Participate in all patient safety initiatives relevant to the position.
  • Maintain professional rapport with providers, patients/families, and internal customers.
  • Train and educate new UM staff nurses and new RN Care Coordinators on job competency and technical instruction.
  • Advocate for appropriate placement of patients to secure correct remuneration.
  • Utilize clinical application systems, utilization review systems, and business support applications.
Qualifications
  • Licensed Registered Nurse in the State of Virginia (or eligible).
  • Current RN licensure in Virginia.
  • Minimum of three (3) years of nursing experience in an acute care setting.
  • Completion of 15 continuing education units per year.
  • Proficiency in Milliman Care Guidelines (MCG) or InterQual criteria for medical necessity, setting and level of care, and concurrent patient management.
Preferred Experience and Credentials
  • One (1) year of Care Coordination experience.
  • Clinical experience with specialty patient populations.
  • Two (2) to Four (4) years of recent experience in Utilization Review or Utilization Management at a health plan or managed care organization (HMO/TPA/IPA/etc.).
  • Master’s Degree in Nursing or a healthcare-related field from an accredited program.
  • Case Management Certification.
Additional Position Requirements
  • Ability to flex the schedule as needed to meet department demands.
  • Physical lifting capacity of 20-50 lbs.; prolonged sitting; repetitive motion.
  • Strong recall, reasoning, problem solving, hearing, speaking, writing, reading, logical thinking.
  • Ability to handle multiple priorities, frequent customer interactions, and adapt to frequent change.
EEO Statement

EEO Employer/Disabled/Protected Veteran/41 CFR 60-1.4.

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