Clinical Reviewer (Part-Time, Remote)

Job Description

Job Description

Job Summary

The purpose of this position is to utilize clinical expertise to review medical records against established criteria in accordance with contract requirements.

Location: Remote (U.S.-based)
Licensure Requirement: Must hold an active clinical license in the State of Indiana or a Compact State license

Work Schedule:

• Up to 25 hours per week
• Weekend and/or holiday availability required  

Training Requirement:

• Must be fully available to attend 100% of training
• Schedule:  Monday–Friday, 9:00 AM – 6:00 PM EST
• Duration:  Minimum of 3 weeks

• Ensure accuracy and timeliness of all review cases in accordance with contract requirements
• Manage daily workload and queues; adjust workflow as needed to meet departmental demands
• Collaborate with Supervisor on quality monitoring and improvement activities
• Maintain current knowledge of clinical practices and review processes
• Serve as a liaison for providers regarding customer service issues and resolution
• Perform various review types as assigned based on workload
• Build and maintain professional relationships with internal and external stakeholders
• Attend required trainings and team meetings
• Cross-train to support business and client needs
• Comply with all corporate policies, including HIPAA Privacy and Security regulations

Note: Responsibilities may evolve based on business needs.

 

• Active, unrestricted  LPN/LVN or RN license in Indiana or Compact State
• Associate’s degree (Bachelor’s preferred) or diploma from an accredited nursing program
• 2+ years of Utilization Review/Management (UR/UM) and/or Prior Authorization experience
• 2+ years of medical necessity review experience
• 1+ year of InterQual and/or Milliman Care Guidelines (MCG) experience
• Strong knowledge of medical records, terminology, and disease processes
• Excellent clinical assessment and critical thinking skills
• Strong written and verbal communication skills
• Ability to navigate multiple systems efficiently
• Strong organizational skills and flexibility

• 3+ years of clinical experience (acute care, behavioral health, and/or med-surgical)
• Knowledge of  NCQA and URAC standards
• Experience working in a team-based environment
• Proficiency in  Microsoft Office
• Strong time management and prioritization skills
• Demonstrated ability to maintain confidentiality and ensure HIPAA compliance