Clinical Review Nurse - Concurrent Review(Denial)

Key Responsibilities: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists with issues and/or questions related to correspondence with the state, local, and federal agencies including third party payer to ensure issues are resolved in a timely manner.

Immediate need for a talented Clinical Review Nurse - Concurrent Review(Denial). This is a 12 Months Contract opportunity with long-term potential and is located in US (Remote). Please review the job description below and contact me ASAP if you are interested.

Job ID:26-25122

Pay Range: $35 - $39/hour.  Employee benefits include, but are not limited to, health insurance (medical, dental, vision), 401(k) plan, and paid sick leave (depending on work location).
 
Key Responsibilities:

• Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. 
• Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member.
• Performs clinical review of outcomes including creating and editing denial letters with the correspondence team based on denial determinations in accordance with National Committee for Quality Assurance (NCQA) standards
• Contributes to correspondence letter template creation and maintenance with the correspondence team
• Investigates denials through comprehensive review of clinical documentation, clinical criteria/guidelines, and policy, including insurance rejections due to coding issues and provides supplemental information to resolve denial claims
• Assists with issues and/or questions related to correspondence with the state, local, and federal agencies including third party payer to ensure issues are resolved in a timely manner
• Maintains and monitors cases to ensure timely resolution and logs of actions and/or decisions are appropriately documented

Key Requirements and Technology Experience:

• Must have skills: -  Minimum 2-year nursing experience. Live anywhere in the U.S.
• Knowledge of Medicare and Medicaid regulations; Knowledge of utilization management
• Associate degree
• Knowledge of Medicare and Medicaid regulations; Knowledge of utilization management
• RN License 

Our client is a leading Healthcare Industry and we are currently interviewing to fill this and other similar contract positions. If you are interested in this position, please apply online for immediate consideration.
 
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