Clinical Review Nurse (Concurrent Review)

Work Mode: 100% Remote – Any US State
Shift: Tuesday - Thursday 9:30 am – 6 pm CST
Duration: 12 Month contract ONLY

Responsibilities:

• Draft correspondence letters based on review outcomes in accordance with National Committee for Quality Assurance (NCQA) standards.
• Perform clinical review of outcomes, including creating and editing denial letters with the correspondence team based on denial determinations.
• Contribute to correspondence letter template creation and maintenance.
• Investigate denials through comprehensive review of clinical documentation, clinical criteria/guidelines, and policy.
• Assist with issues and/or questions related to correspondence with state, local, and federal agencies.
• Maintain and monitor cases to ensure timely resolution and documentation.
• Coordinate with interdepartmental teams on training needed within the utilization management team.
• Provide feedback to leadership to improve clinical processes and procedures.
• Comply with all policies and standards.

Requirements:

• Graduated from an accredited school of nursing or A.D. or bachelor’s in nursing.
• Active LPN or RN licensure in any state.
• Minimum 1 year of nursing experience.
• Ability to critically think.
• Proficiency in Microsoft OneNote and Word.
• Ability to work remotely and meet production deadlines and quality metrics.

Preferred Skills:

• Knowledge of Medicare and Medicaid regulations.
• Experience in utilization management.