Weekend 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.
• Communicates consistently with providers and facility staff.
• Consults with Medical Directors on care that does not meet criteria.
• Documents clinical information accurately and timely.
• Meets or exceeds production and quality metrics.
• Maintains understanding of authorization requirements and clinical criteria.
• Identifies Clinical Program opportunities for members.
• Collaborates with various teams to ensure consistent application of clinical criteria.
• Ensures compliance with accreditation and regulatory requirements.
• Supports quality improvement activities.

Requirements

• Registered Nurse with active license.
• Minimum of 3 years of clinical experience.
• Utilization Management experience required.
• MCG certification preferred.
• Experience in acute care or post-acute care environments.
• Excellent communication skills.
• Ability to work cross-functionally.
• Knowledge of NCQA and CMS standards.
• Proficient in CMS and MCG guidelines.
• Bachelor’s degree preferred.

Benefits

• 100% remote role.
• Computer equipment provided.
• Health insurance included.
• 401k plan available.
• Bonus opportunities.