Full-Time Nurse - Clinical Review

• Performs utilization review of cases to determine if the request meets medical necessity criteria.
• Facilitates resolution of escalated cases that may require special handling.
• Performs clinical reviews according to policies and procedures.
• Collaborates with client personnel to resolve customer concerns.
• Identifies and refers quality issues to UM Leadership.
• Assists Physician Reviewers and Medical Directors, as necessary.
• Maintains written documentation according to policy.
• Ensures consistency in implementation of policy, procedure, and regulatory requirements.
• Keeps current with regulation changes.
• Adheres to all HIPAA, state, and federal regulations.
• Provides quality customer service.
• Supports an environment that fosters teamwork, respect, diversity, and cooperation.
• Engages in phone conversations to facilitate the clinical review process.
• Effectively utilizes various computer systems and software.
• Promotes business focus.
• Participates in the Quality Management Program, as required.
• Adheres to both URAC & NCQA standards.
• Ability to prioritize projects, work independently under pressure, and meet critical deadlines.
• Capable of communicating clinical concepts to providers and staff based on guidelines.
• Performs other related duties and projects as assigned.

• RN, LPN/LVN graduate from an accredited school of nursing
• Current, active unrestricted RN, LPN/LVN license in the state or territory of the U.S.
• Minimum of two (2) years experience in utilization review, case management, utilization management.
• Proficient technical skills in Microsoft Office and ability to adapt to new healthcare specific software and systems, required
• Experience working with state and federal regulatory and compliance standards, preferred
• Working knowledge of National Coverage Determination (NCD) and Local Coverage Determination (LCD)
• Knowledge of insurance terminology
• Good organizational and time management skills
• Excellent written and verbal communication skills
• Ability to utilize critical thinking skills
• Highly motivated, self-starter who can work efficiently and independently, or as a team member

What is the last date for applying to the job?

Which countries are accepted for this remote job?