Nurse Reviewer - Remote

All candidates must have valid work authorization in the United States without need for visa-sponsorship

Remote or hybrid or in person and shift hours will be Alaska time

Summary

We are seeking a talented individual for a Nurse Reviewer who will be responsible for performing clinical reviews to determine if the medical record documentation supports the need for the service based on clinical criteria, coverage policies, and utilization and practice guidelines as defined by review methodologies specific to the contract for which services are being provided. This involves accessing proprietary systems to audit medical records, accurately documenting findings and providing policy/regulatory support for determination.

Your role in our mission

• Document decisions and rationale to justify review findings or no findings.
• Performs prior authorization, precertification, and retrospective reviews and prepares decision letters as needed in support of the utilization review contract
• Actively cross-trains to perform reviews of multiple claim types to provide a flexible workforce to meet client needs.
• Responsible for attending training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations.
• Maintains current knowledge of clinical criteria guidelines and successfully completes required CEUs to maintain RN license
• Assists management with training new Nurse Reviewers to include daily monitoring, mentoring, feedback and education.
• Determines approval or initiates a referral to the physician consultant and processes physician consultant decisions ensuring reason for the denial is described in sufficient detail and completed within contractual deadline.
• Reviews and interprets medical records and compares against criteria to determine appropriateness and reasonableness of care; apply critical thinking and decision making skills to determine if the medical record documentation supports the need for service while maintaining production goals and quality standards.
• Recommends, tests and implements process improvements, new audit concepts, and technology improvements that will enhance production, quality, and client satisfaction

What we're looking for

• Demonstrated proficiency in computer skills, and typing, i.e., Microsoft Windows, Outlook, Excel, Word, PowerPoint, Internet browsers, etc.
• Experience using Milliman or InterQual criteria required
• 5+ years clinical experience in an inpatient hospital setting required
• 2+ years utilization review experience or claims auditing required
• Active and unrestricted RN license required

What you should expect in this role

• May be required to travel at least 10% of time based on business needs
• May be required to work extended hours for special business needs
• Home based position and you must have a work location within the continental US
• This position requires that you provide high speed internet connection and a work environment free from distractions
• Ability to work during normal business hours as this position requires frequent interactions with the team and other departments within the company

Job Posted by ApplicantPro