Clinical Review Nurse

Job TitleLocation: 100% Remote – Any US State Shift: Fri-Sat-Sun-Mon 8:30 am – 6 pm CST Overtime may be required and Holidays are required Duration: 12monthsJob Profile Summary: Will be working with the IL and MI Medicaid products. The purpose of the team is to ensure that the members and requesting providers receive the written documentation of a denied service. Candidate may live anywhere in the U.S.Responsibilities: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) standardsContributes to correspondence letter template creation and maintenance with the correspondence teamInvestigates 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 claimsAssists 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 mannerMaintains and monitors cases to ensure timely resolution and logs of actions and/or decisions are appropriately documentedCoordinates with interdepartmental teams on training needed within the utilization management team based on trendsProvides feedback to leadership to improve clinical processes and procedures to prevent recurrences based on industry best practicesPerforms other duties as assignedComplies with all policies and standardsCandidate 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 experienceLicensure - Required: LPN or RN, active in any state - Preferred: CompactYears 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 qualityTop 3 must-have hard skills stack-ranked by importance - 1 - Ability to critically think2 - Ability to effectively use Microsoft OneNote and Word3 - Ability to work remotely, i.e. meet production deadlines; quality metrics