Nurse - Clinical Review - Remote

Overview

The Nurse - Clinical Review position involves performing utilization reviews to determine medical necessity, facilitating case resolutions, and collaborating with clients to ensure quality care in accordance with healthcare regulations.

In Short

• Perform utilization review of cases for medical necessity.
• Facilitate resolution of escalated cases.
• Collaborate with client personnel for customer concerns.
• Maintain documentation according to policies.
• Ensure compliance with review timeframes.
• Adhere to HIPAA and regulatory standards.
• Engage with providers and staff for clinical review processes.
• Utilize computer systems for case management.
• Participate in quality management programs.
• Communicate clinical concepts effectively.

Requirements

• RN, LPN/LVN graduate from an accredited nursing school.
• Current unrestricted RN, LPN/LVN license.
• Minimum of two years clinical or administrative experience.
• Experience in utilization review or case management preferred.
• Proficient in Microsoft Office and healthcare software.
• Knowledge of insurance terminology.
• Strong organizational and time management skills.
• Excellent written and verbal communication skills.
• Ability to utilize critical thinking skills.
• Self-motivated and able to work independently.

Benefits

• Medical, dental, and vision insurance.
• Paid time off (PTO), holidays, and sick leave.
• 401(k) with company match.
• Life and AD&D insurance.
• Employee Assistance Program.