Clinical Reviewer

Job Description Job Description Job Summary The purpose of this position is to utilize clinical expertise to review medical records against established criteria in accordance with contract requirements.
Location: Remote (U.S.-based)
Licensure Requirement: Must hold an active clinical license in the State of Indiana or a Compact State license
Work Schedule:
40 hours per week
Weekend and/or holiday availability required
Training Requirement:
Must be fully available to attend 100% of training
Schedule: Monday–Friday, 9:00 AM – 6:00 PM EST
Duration: Minimum of 3 weeks
Key Responsibilities Ensure accuracy and timeliness of all review cases in accordance with contract requirements
Manage daily workload and queues; adjust workflow as needed to meet departmental demands
Collaborate with Supervisor on quality monitoring and improvement activities
Maintain current knowledge of clinical practices and review processes
Serve as a liaison for providers regarding customer service issues and resolution
Perform various review types as assigned based on workload
Build and maintain professional relationships with internal and external stakeholders
Attend required trainings and team meetings
Cross-train to support business and client needs
Comply with all corporate policies, including HIPAA Privacy and Security regulations
Note: Responsibilities may evolve based on business needs.

Required Qualifications Active, unrestricted LPN/LVN or RN license in Indiana or Compact State
Associate’s degree (Bachelor’s preferred) or diploma from an accredited nursing program
2+ years of Utilization Review/Management (UR/UM) and/or Prior Authorization experience
2+ years of medical necessity review experience
1+ year of InterQual and/or Milliman Care Guidelines (MCG) experience
Strong knowledge of medical records, terminology, and disease processes
Excellent clinical assessment and critical thinking skills
Strong written and verbal communication skills
Ability to navigate multiple systems efficiently
Strong organizational skills and flexibility
Preferred Qualifications 3+ years of clinical experience (acute care, behavioral health, and/or med-surgical)
Knowledge of NCQA and URAC standards
Experience working in a team-based environment
Proficiency in Microsoft Office
Strong time management and prioritization skills
Demonstrated ability to maintain confidentiality and ensure HIPAA compliance
Weekend and holiday flexibility is required

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