Clinical Review Nurse

Summary:

• Work Mode: 100% Remote – Any US State
• Duration: 12 months
• Shift: Fri-Sat-Sun-Mon 8:30 am – 6 pm CST
• Overtime may be required and Holidays are required

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 based on denial determinations in accordance with NCQA standards.
• Contribute to correspondence letter template creation and maintenance.
• Investigate denials through comprehensive review of clinical documentation, clinical criteria/guidelines, and policy, providing supplemental information to resolve denial claims.
• Assist with issues and/or questions related to correspondence with state, local, and federal agencies including third-party payers to ensure timely resolution.
• Maintain and monitor cases to ensure timely resolution and appropriate documentation of actions and/or decisions.
• Coordinate with interdepartmental teams on training needed within the utilization management team based on trends.
• Provide feedback to leadership to improve clinical processes and procedures to prevent recurrences based on industry best practices.
• Perform other duties as assigned.
• Comply with all policies and standards.

Requirements:

• Graduated from an accredited school of nursing or A.D. or bachelor’s in nursing.
• LPN or RN, active in any state.
• Minimum 1 year of nursing experience.
• Ability to critically think.
• Ability to effectively use Microsoft OneNote and Word.
• Ability to work remotely, i.e., meet production deadlines; quality metrics.

Preferred Skills:

• 2-4 years of related experience.
• Compact licensure.
• Knowledge of Medicare and Medicaid regulations.
• Knowledge of utilization management.