Remote Clinical Review RN - 254753

Job Title: Clinical Review RN (IDR/Appeals)

Experience: Open to various clinical backgrounds/experience. Appeals experience not required. Must have 2+ years of clinical experience post graduation, must has critical thinking and problem solving skills.

***Must have BSN and New York State RN license***

Location: Remote (can sit anywhere in the US as long as you can work EST hours)

Hours of Operation: M-F 7a-5:30p *flexible start between 7am-9am (40hrs/wk)

Start date: ASAP

Pay: $50-53/hr DOE

GENERAL RESPONSIBILITIES:

This individual will complete the full spectrum of activities related to State and Federal Independent Dispute Resolution (IDR) case determinations. They will conduct clinical level review, Prior Authorization, and disputed benefits review, supporting Medical Review Analysts, and Physician Consultants to ensure an appropriate and accurate process.

DUTIES:

1. Conduct reviews up to and including the appeal level. This includes chart screen, compiling

regulatory guidance, researching insurer requirements, complete electronic worksheets and

preparing final determinations.

2. Act as a resource for the administrative and clinical staff in training, problem solving, and

clarifying determinations. Will provide technical assistance and conduct/participate in staff

huddles.

3. Training and mentoring new RNs as the project expands.

4. Claims assessment and adjudication.

5. Participate in collaborative training.

6. Other activities as may be deemed necessary.

QUALIFICATIONS:

1. Knowledge and experience with electronic medical records.

2. Ability to oversee, problem solve, and work collaboratively with peers, medical, analytical, and

administrative support staff.

3. Excellent written and verbal skills.

4. Ability to work independently with little supervision.

5. Ability and desire to be flexible, innovative, and creative.

6. Ability to meet deadlines in a time sensitive environment.

EDUCATION AND EXPERIENCE:

1. Licensed, Registered Nurse in NYS, required.

2. BSN required OR bachelor's degree + ASN is acceptable

3. Minimum of two years’ experience in a clinical setting, required