Senior Clinical Review Nurse - Correspondence - Remote

Overview

As a Senior Clinical Review Nurse, you will play a crucial role in ensuring quality healthcare for our members by drafting correspondence and conducting clinical reviews in accordance with NCQA standards.

In Short

• Drafts correspondence letters and supports team needs.
• Reviews clinical outcomes based on NCQA standards.
• Identifies improvement opportunities with senior management.
• Conducts clinical reviews and edits denial letters.
• Audits correspondence for compliance with regulations.
• Investigates denial claims and resolves issues.
• Acts as a liaison for correspondence-related inquiries.
• Monitors cases for timely resolution.
• Provides education on utilization management trends.
• Complies with all policies and standards.

Requirements

• Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing.
• 4 – 6 years of related experience required.
• Expertise in Medicare and Medicaid regulations preferred.
• Expertise in utilization management processes preferred.
• RN or LPN state licensure required.

Benefits

• Competitive pay and comprehensive benefits package.
• Health insurance and 401K options.
• Tuition reimbursement and paid time off.
• Flexible work schedules including remote options.
• Commitment to diversity and equal opportunity.