Case Review Specialist

Case Review Specialist- RN reqd
Full-time and per diem available
Position Purpose
As the Case Review Specialist (RN), you will be responsible for the review and processing
of all requests for Independent Reviews from External Agencies in accordance with
contract guidelines. Upon receipt of the medical records, communicate with contractors,
providers and beneficiary/representatives. In applicable cases, perform case review
utilizing InterQual criteria and clinical knowledge for medical necessity and quality of care
issues and coordinate with coding specialist for cases requiring diagnosis related groups
validation. Formulate a case summary and the review questions for the Physician
Reviewer based upon the External Agencys concern(s). Review physician
determinations, ensuring all categories of concern have been addressed. Prepare written
correspondences to contractors, providers and beneficiaries/representatives. Maintain
contractual timeframes and URAC standards for case completion. Interface with Medical
Director.
Full-time: in-office, Mon.- Fri., no weekends or holidays
Per diem: remote, up to 20 hrs. per week
Qualifications
The ability to communicate effectively and interact with providers, internal customers
and beneficiaries/ representatives
Excellent written and oral communication skills and professional demeanor
The ability to work independently, as well as in a team environment
Proficient in the use of standard EHR applications, office technology and Microsoft
applications including Word, Excel, and PowerPoint
Ability to handle sensitive and confidential information
Minimum Education & Experience
Licensed Registered Nurse in CA, required
Graduate of a School of Nursing, required
Bachelor of Science in Nursing (BSN), preferred
A minimum of three (3) years clinical experience in an acute care setting or related
experience, required.
Experience in utilization and quality reviews, required
Experience in the application of InterQual criteria, preferred
Experience in managed care, quality management and peer review, preferred
HOW TO APPLY:
Interested candidates must note the position identified in the title line when
applying for this position.
Please submit a resume, along with a cover letter (which should include salary
requirements and full-time or per diem preference) to:
Lumetra Healthcare Solutions
550 Kearny Street Suite 300
San Francisco, CA 94108
View email address on click.appcast.io.
While we are grateful for all interest expressed in employment with Lumetra, only qualified
candidates being considered will be contacted.
Lumetra is an Equal Opportunity/Affirmative Action Employer;
Minority/Female/Disabled/Veteran