Clinical Review Nurse

Job Title

Location: 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: 12months

Job 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) standards
• Contributes to correspondence letter template creation and maintenance with the correspondence team
• Investigates 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 claims
• Assists 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 manner
• Maintains and monitors cases to ensure timely resolution and logs of actions and/or decisions are appropriately documented
• Coordinates with interdepartmental teams on training needed within the utilization management team based on trends
• Provides feedback to leadership to improve clinical processes and procedures to prevent recurrences based on industry best practices
• Performs other duties as assigned
• Complies with all policies and standards

Candidate 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 experience

Licensure - Required: LPN or RN, active in any state - Preferred: Compact

Years 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 quality

Top 3 must-have hard skills stack-ranked by importance - 1 - Ability to critically think

2 - Ability to effectively use Microsoft OneNote and Word

3 - Ability to work remotely, i.e. meet production deadlines; quality metrics