RN Reviewer - Remote

Overview

The RN Reviewer position is a crucial role in our organization — in this role you are responsible for performing a full range of activities that will positively impact the organization and contribute to guiding the strategic operations for the company.

In Short

• Performs medical necessity review including inpatient, concurrent, prior authorization, and retrospective reviews.
• Consults with Medical Directors on care that does not meet criteria.
• Documents clinical information accurately and timely.
• Meets production and quality metrics.
• Maintains understanding of provider and member centric focus.
• Identifies Clinical Program opportunities.
• Collaborates with multiple stakeholders.
• Ensures compliance with accreditation and regulatory requirements.
• Supports quality improvement activities.
• Performs other duties as assigned.

Requirements

• Registered Nurse with active license.
• Minimum of 3 years clinical experience.
• Utilization Management experience required.
• Experience in acute care environments preferred.
• Excellent communication skills.
• Knowledge of NCQA and CMS standards.
• Proficient in MCG guidelines.
• Bachelor’s degree preferred.
• Ability to work in a fast-paced environment.
• Strong customer service skills.

Benefits

• Health insurance.
• 401k.
• Bonus opportunities.
• Remote work flexibility.
• Supportive work environment.
• Growth opportunities.
• Continuous quality improvement focus.
• Collaborative team culture.
• Access to training and development.
• Recognition for contributions.