Clinical Review Nurse - Concurrent Review

Job Title: Clinical Review Nurse - Concurrent Review
Location: Remote -Anywhere in US
Shift : Tuesday - Thursday 9:30 am - 6 pm CST / Overtime may be required and Holidays are required
Duration : 12 months

Position Purpose:
Drafts correspondence letters based on review outcomes in accordance with National Committee for Quality Assurance (NCQA) standards. Works with senior management to identify and implement opportunities for improvement.

• 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
• Coordinates with interdepartmental teams on training needed within the utilization management team based on trends
• Provides feedback to leadership to improve clinical processes and procedures to prevent recurrences based on industry best practices
• Performs other duties as assigned
• Complies with all policies and standards

Candidate Requirements Education/Certification Required: Requires graduated from an accredited school of nursing or A.D. or bachelor's in nursing Preferred: 2-4 years of related experience Licensure Required: LPN or RN, active in any state Preferred: Compact Years of experience required:

Must haves: Minimum 1 year nursing experience. Live anywhere in the U.S.

Nice to haves: Knowledge of Medicare and Medicaid regulations; Knowledge of utilization management

Disqualifiers:

Performance indicators: Metric driven in production and quality

• Top 3 must-have hard skills stack-ranked by importance

1 Ability to critically think 2 Ability to effectively use Microsoft OneNote and Word 3 Ability to work remotely, i.e. meet production deadlines; quality metrics