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Clinical Review Nurse Jobs

Medical Review Nurse (Mrac)
By Provider Resources, Inc. At , Columbia, 29203
Engage clients in appropriate communication that manages client expectations and builds a collaborative relationship with the client
Make clinical judgments based on clinical experience when applicable
Understand and represent PRI?s mission, vision, and values to all internal and external customers
Perform medical record and claims review in accordance with all State and Federal mandated regulations
Maintain compliance with all regulation changes as they impact medical and utilization review practices
Analyze patient records and participate in interdisciplinary collaboration with PRI staff and all recognized teaming partners and/or subcontractors
Medical Review Nurse (Mrac)
By Provider Resources, Inc. At ,
Engage clients in appropriate communication that manages client expectations and builds a collaborative relationship with the client
Make clinical judgments based on clinical experience when applicable
Understand and represent PRI’s mission, vision, and values to all internal and external customers
Perform medical record and claims review in accordance with all State and Federal mandated regulations
Maintain compliance with all regulation changes as they impact medical and utilization review practices
Analyze patient records and participate in interdisciplinary collaboration with PRI staff and all recognized teaming partners and/or subcontractors
Clinical Quality Review Nurse Trainer/Auditor - Consultant
By Blue Shield of California At , Woodland Hills, 91367 $109,120 - $163,680 a year
Conduct periodic needs assessments to identify knowledge gaps
Requires a bachelors degree or equivalent experience
Requires at least 7 years of prior relevant experience
Requires 3-5 plus years hands-on clinical experience across a variety of specialties and settings
Preferred Nursing Informatics experience and/or degree
Strong verbal/written communication and organizational skills
Medical Review Nurse (Mrac)
By Provider Resources, Inc. At , Baltimore, 21244
Engage clients in appropriate communication that manages client expectations and builds a collaborative relationship with the client
Make clinical judgments based on clinical experience when applicable
Understand and represent PRI?s mission, vision, and values to all internal and external customers
Perform medical record and claims review in accordance with all State and Federal mandated regulations
Maintain compliance with all regulation changes as they impact medical and utilization review practices
Analyze patient records and participate in interdisciplinary collaboration with PRI staff and all recognized teaming partners and/or subcontractors
Medical Review Nurse Auditor
By Performant Financial Corporation At , Remote
Experience with utilization management systems or clinical decision making tools such as MCG or InterQual.
Other duties, responsibilities, and qualifications may be required and/or assigned as necessary
Typing skills and working knowledge of computer functions and applications such as MS office (Outlook, Word, Excel).
Works collaboratively with the audit team to identify vulnerabilities and/or cases subject to potential Fraud Waste and Abuse (FWA).
Maintain a current knowledge of Medicare and Commercial regulations, policies and procedures
Maintain coding certification to ensure eligibility to perform audits on behalf of Performant
Clinical Review Coordinator - National Remote
By Optum At , Dallas, 75202
2+ years of Case Management experience
Experience in acute care, rehab, OR skilled nursing facility environment
Ability to work effectively in a self- management environment
Support new delegated contract start - up to ensure experienced staff work with new contracts
Perform other duties and responsibilities as required, assigned or requested
3+ years of clinical experience
Manager Clinical Quality Review
By Johns Hopkins University At , Baltimore, 21218

EDUCATION LICENSURE & EXPERIENCE :

Benefits can be viewed here:

Medical Review Nurse (Government Outpatient Clinical Focus)
By Performant Financial Corporation At , Remote
Experience with utilization management systems or clinical decision making tools such as Medical Coverage Guidelines (MCG) or InterQual.
Working collaboratively with the audit team to identify and obtain approval for particular vulnerabilities and/or cases subject to potential abuse
Work in partnership with our clients, CMD colleagues, and other contractors on improving medical policies, provider education, and system edits
Strong preference for experience performing utilization review for an insurance company, Tricare, MAC or organizations performing similar functions
Experience with ICD-9, ICD-10, CPT-4 or HCPCS coding.
Knowledge of insurance programs program, particularly the coverage and payment rules.
Medical Claims Review Nurse
By Healthcare Management Administrators Inc At ,
Retrospective utilization management case review
Knowledge, Experience, and Key Attributes needed for Success:
2+ years of clinical nursing experience
Knowledge of Utilization Review processes
Knowledge of the medical plan appeal process (preferred)
Strong experience in clinical practice with diverse diagnoses
Concurrent Review Nurse-( Auditor)- Metro, East, Northeast
By MMM Holdings At , San Juan
One to three years experience in utilization management or health services setting preferred.
Five years clinical acute care hospital experience; ICU, Emergency Medicine Department, Medical / Surgical Department.
Must have ability to work as a team player with excellent verbal and written communication skills.
Familiarity with State Federal Governmental regulations and national accrediting agency requirement preferred (CMS/NCQA or regulatory agencies).
Performs tasks requiring independent knowledge judgment in addition to instructions and procedures provided.
Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.
Medical Review Nurse (Government Outpatient Clinical Focus)
By Performant Corp At United States
Experience with utilization management systems or clinical decision making tools such as Medical Coverage Guidelines (MCG) or InterQual.
Working collaboratively with the audit team to identify and obtain approval for particular vulnerabilities and/or cases subject to potential abuse
Work in partnership with our clients, CMD colleagues, and other contractors on improving medical policies, provider education, and system edits
Strong preference for experience performing utilization review for an insurance company, Tricare, MAC or organizations performing similar functions
Experience with ICD-9, ICD-10, CPT-4 or HCPCS coding.
Knowledge of insurance programs program, particularly the coverage and payment rules.
Clinical Review Nurse I
By Elevance Health At Hingham, MA, United States
Medicare Part B Appeals experience preferred.
Job Family: Medical and Clinical
Conducts investigations and reviews of member and provider grievances and appeals.
Generates appropriate written correspondence to providers, members, and regulatory entities.
Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.
Adapts to a wide variety of medical review topics in Part B appeals.
Clinical Review Nurse I
By Elevance Health At Atlanta, GA, United States
Medicare Part B Appeals experience preferred.
Job Family: Medical and Clinical
Conducts investigations and reviews of member and provider grievances and appeals.
Generates appropriate written correspondence to providers, members, and regulatory entities.
Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.
Adapts to a wide variety of medical review topics in Part B appeals.
Medical Review Nurse - Entry Level
By Qlarant At Dallas, TX, United States
Quality Management - Looks for ways to improve and promote quality; Demonstrates accuracy and thoroughness.
Experience in ICD-9 coding, CPT coding, and knowledge of Medicare and/or Medicaid regulations.
Current RN license. An LVN will not meet the contract's requirements.
Employment history that shows progressively responsible experience.
Strong Medicare and/or Medicaid knowledge.
Completes desk review or field audits to meet applicable contract requirements and to identify evidence of potential overpayment or fraud.
Inpatient Review Nurse Jobs
By Bright Health At Anaheim, CA, United States
Three (3) years of utilization management and quality improvement experience are required.
Working knowledge and understanding of basic utilization management concepts are required.
Education, Training, And Professional Experience
Experience interpreting clinical criteria into clear determinations.
Excellent writing skills, particularly in determination notification writing.
Escalates all potential quality issues and grievances to correct Bright workflows
Clinical Review Nurse Jobs
By Abbott At Kansas City, MO, United States
3-5 years’ minimum experience in Occupational health settings, hospital, and outpatient nursing
Career development with an international company where you can grow the career you dream of.
Free medical coverage for employees* via the Health Investment Plan (HIP) PPO
An excellent retirement savings plan with high employer contribution
Provide subject matter expertise in executing Drug Testing Services across Workplace Solutions broad customer base.
Interpret and report results of Workplace clients consistent with Workplace Solutions written Standard Operating Procedures.
Clinical Review Coordinator - Remote | Wfh
By Get It Recruit - Healthcare At Dallas, TX, United States

We are seeking a passionate and dedicated healthcare professional to join our dynamic team! As a member of our organization, you will play a pivotal role in ensuring the highest quality of care for ...

Clinical Review Coordinator - National Remote
By RemoteWorker US At Hartford, CT, United States
2+ years of Case Management experience
Experience in acute care, rehab or skilled nursing facility environment
Ability to work effectively in a self-management environment
Support new delegated contract start-up to ensure experienced staff work with new contracts
Perform other duties and responsibilities as required, assigned or requested.
3+ years of clinical experience
Clinical Access Nurse - Rn, Weekend, Olol Discharge Planning Utilization Review
By Franciscan Missionaries of Our Lady Health System At , Baton Rouge, 70808, La
Experience - 3 years in general or specialty nursing practice
Education - Diploma, Associate's Degree or Bachelor's Degree from accredited RN program
License - Current and unrestricted Louisiana RN license
Coordinates appropriate bed placement in conjunction with Patient Care Services and the Bed Coordinator.
Performs other duties as assigned or requested.
Medical Review Nurse (Snf Focus)
By Performant Financial Corporation At , Remote
Experience with utilization management systems or clinical decision making tools such as Medical Coverage Guidelines (MCG) or InterQual.
Working collaboratively with the audit team to identify and obtain approval for particular vulnerabilities and/or cases subject to potential abuse
Work in partnership with our clients, CMD colleagues, and other contractors on improving medical policies, provider education, and system edits
Strong preference for experience performing utilization review for an insurance company, Tricare, MAC or organizations performing similar functions
Experience with ICD-9, ICD-10, CPT-4 or HCPCS coding.
Knowledge of insurance programs program, particularly the coverage and payment rules.

Are you a Clinical Review Nurse looking for a new challenge? Join our team and help us make a difference in the lives of our patients! We offer a competitive salary and benefits package, flexible hours, and a supportive team environment. Come join us and make a positive impact in the healthcare industry!

Overview:

A Clinical Review Nurse is a healthcare professional who is responsible for reviewing medical records and making decisions about the appropriateness of care provided to patients. They are responsible for ensuring that the care provided is in accordance with established standards of practice and that it is medically necessary. Clinical Review Nurses also provide guidance to healthcare providers on the most appropriate course of treatment for a patient.

Detailed Job Description:

Clinical Review Nurses are responsible for reviewing medical records to ensure that the care provided is medically necessary and in accordance with established standards of practice. They must be able to interpret medical records and make decisions about the appropriateness of care provided. Clinical Review Nurses must also be able to provide guidance to healthcare providers on the most appropriate course of treatment for a patient. They must be able to communicate effectively with healthcare providers and patients to ensure that the care provided is appropriate and meets the patient's needs.

What is Clinical Review Nurse Job Skills Required?

• Knowledge of medical terminology and anatomy
• Knowledge of medical coding and billing
• Knowledge of healthcare regulations and standards
• Ability to interpret medical records
• Ability to make decisions about the appropriateness of care provided
• Ability to provide guidance to healthcare providers
• Excellent communication and interpersonal skills
• Ability to work independently and as part of a team

What is Clinical Review Nurse Job Qualifications?

• Bachelor’s degree in Nursing or a related field
• Current Registered Nurse (RN) license
• Certification in Clinical Review Nursing (CCRN)
• Experience in a clinical setting
• Knowledge of medical coding and billing

What is Clinical Review Nurse Job Knowledge?

• Knowledge of medical terminology and anatomy
• Knowledge of healthcare regulations and standards
• Knowledge of medical coding and billing
• Knowledge of clinical review processes

What is Clinical Review Nurse Job Experience?

• Experience in a clinical setting
• Experience in medical coding and billing
• Experience in clinical review processes

What is Clinical Review Nurse Job Responsibilities?

• Review medical records to ensure that the care provided is medically necessary and in accordance with established standards of practice
• Interpret medical records and make decisions about the appropriateness of care provided
• Provide guidance to healthcare providers on the most appropriate course of treatment for a patient
• Communicate effectively with healthcare providers and patients to ensure that the care provided is appropriate and meets the patient's needs
• Monitor patient outcomes to ensure that the care provided is effective
• Maintain accurate records of all reviews and decisions made