Remote RN, Clinical Record Review

Applicants must reside in: Michigan, Florida, Idaho, Texas, Minnesota or Illinois. Must be able to work 12 pm - 8 pm EST, Monday through Friday, with rotating on call coverage for weekends and holidays.

We are searching for a new RN to join our team. Our Nurses enjoy the flexibility to work remotely and do not have face-to-face Patient contact. This position is performed in a home-office environment and requires great telephonic/customer service and documentation skills in addition to clinical experience. Please review the roles and responsibilities of this position below. Please complete all application questions and follow-up assessments. Incomplete applications will not be accepted.

• Upon receipt of a case, verify the presence of any real or perceived conflict of interest, consistent with corporate policy (Ref: Policy and Procedure- Conflict of Interest).
• As applicable, based on the HCR service type requested, review medical records for completeness, verify the appropriate service, Physician Reviewer Specialty, and appropriate review questions upon review of the case
• Maintain communication with the Physician Reviewer (as applicable) during the review process to ensure timely and accurate delivery of the review service being completed.
• Verifies current credentials for the Physician Reviewer. Verify that credentialing has not expired and is completely consistent with corporate policy (Ref: MMRO Credentialing Policy & Procedure).
• Maintain communication, including but not limited to any delays in service, with the referring party as required for the case type being performed.
• As applicable, discuss and review training material with Physician Reviewers.
• Maintain policy and process requirements for State Mandated External Reviews, including the submission of all required correspondence and documentation consistent with state requirements.
• Accurately and consistently document all required case activities in W5.
• Accurately inputs Physician Reviewer cost and client charge into W5 for invoicing/payment by the Bookkeeper.
• Quality review rough draft versions of HCR reports to ensure clinical quality and compliance, including but not limited to: clinical quality issues (i.e. clinical substantiation, clinical inconsistences, plan language compliance) incomplete reports, report inconsistencies, and grammar or typographical errors.
• Communicate, verbally or in writing, with the Physician Reviewer, to remediate any quality issues identified, consistent with corporate policy.
• Assist the Physician Reviewer, as applicable, in selecting and utilizing evidence-based criteria and support of clinical rationale.
• Perform final review of HCR reports in preparation of submitting to client.
• As applicable, participate in Physician Reviewer orientation/training programs, including the development of customized or individualized physician orientation and training programs.
• As applicable, participate in the Quality Improvement Committee and/or participate in Quality Improvement Projects, as requested by the Quality Department.
• Address ongoing quality issues with the Quality Department and suggest quality improvement initiatives, as deemed appropriate.

Required Qualifications and Education

• Current unrestricted RN state license
• Graduate from an accredited School of Nursing, approved by the applicable state Board of Nursing. Degree shall include a Bachelor of Science in Nursing (B.S.N.) or Associate Degree in Nursing (A.D.N.)
• Thorough knowledge of computer operation and software applications related to work performed
• A minimum of two (2) years related experience, specifically in the healthcare insurance industry, preferably in the capacity of Appeals/Grievances, Case Management, Utilization Review or Quality Assurance Specialist.
• Ability to work independently and maintain confidentiality
• Ability to communicate effectively and work co-operatively with Physician Reviewers, co-workers and clients
• Strong verbal and written communication skills
• Familiarity with MLA, NLM, and other citation standards
• Self-directed with positive attitude
• Must be able to work 12 pm - 8 pm EST, Monday through Friday, with rotating on call coverage for weekends and holidays.