Clinical Review Nurse - Remote

Clinical Review Nurse - Remote

ARC Group has multiple positions open for Clinical Review Nurses! These positions are 100% remote. These are direct hire FTE positions with salary, benefits, etc. This is a fantastic opportunity to join a dynamic and well-respected organization offering tremendous career growth potential. At ARC Group, we are committed to fostering a diverse and inclusive workplace where everyone feels valued and respected. We believe that diverse perspectives lead to better innovation and problem-solving. As an organization, we embrace diversity in all its forms and encourage individuals from underrepresented groups to apply.

100% REMOTE! Candidates must currently have PERMANENT US work authorization.

Summary Statement: The Clinical Review Nurse is responsible for reviewing and making medical determinations as to the validity of health claims and levels of payment in meeting national and local policies as well as accepted medical standards of care. The incumbent applies clinical knowledge to assess the medical necessity, level of services and appropriateness of care which may include cases requiring prior authorization, complex pre-payment medical review or post-payment medical review.

Essential Duties & Responsibilities: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This list of essential job functions is not exhaustive and may be supplemented as necessary.

90% of time will be spent on one or more of the following activities depending on assignments:

• Review and analyze pre and post pay complex health care claims from a medical perspective, inclusive of prior authorization:
• Perform clinical review work as assigned; may provide guidance to other team members and accurately interpret and apply broad CMS guidelines to specific and highly variable situations.
• Conduct review of claim data and medical records to make clinical decisions on the coverage, medical necessity, utilization and appropriateness of care per national and local policies, as well as accepted medical standards of care.
• Review provider practices and identify issues of concern, overpayment and need for corrective action as necessary; includes surfacing potential fraud and abuse or practice concerns.
• May develop recommendations for further corrective action based on medical review findings.
• May refer for review, or implement, corrective action related to medical review activities.
• May process claims and complete project work in the appropriate computer system(s).

The remaining 10% of time will be spent on the following activities depending on assignments:

• Identify providers needing education and individually educate providers who are subject to medical review processes:
• Initiate or participate in provider teaching activities, creating written teaching material, providing one on one education or education to a group as a result of a medical review (e.g., probe, progressive corrective action, consent, etc.) or appeal.
• This may involve discussion with CMS leaders and leaders in the provider community.
• Participate in special projects as assigned.

Required Qualifications:

• Valid nursing degree
• 2 years' clinical experience
• Excellent written and oral communication skills
• Demonstrated experience with evaluating medical and health care delivery issues (e.g., Inpatient Rehab Facility)
• Strong computer skills to include Microsoft Office proficiency
• Valid unrestricted Registered Nurse (RN) license

Preferred Qualifications:

• Inpatient Rehabilitation Facility Experience
• Bachelor of Science in Nursing (BSN)
• Insurance industry experience
• Certified Coder

ARC Group is a Forbes-ranked a top 20 recruiting and executive search firm working with clients nationwide to recruit the highest quality technical resources. We have achieved this by understanding both our candidate's and client's needs and goals and serving both with integrity and a shared desire to succeed. At ARC Group, we are committed to providing equal employment opportunities and fostering an inclusive work environment. We encourage applications from all qualified individuals regardless of race, ethnicity, religion, gender identity, sexual orientation, age, disability, or any other protected status. If you require accommodations during the recruitment process, please let us know. Position is offered with no fee to candidate.

American Recruiting & Consulting Group