[Hiring] Clinical Reviewer - RN - PRN @reputed company

Role Description reputed company is looking for a Clinical Reviewer - RN - PRN (Remote U.S.) to join our growing team. Job Summary:

• Review medical records against criteria, contract requirements, and regulatory standards.
• reputed company critical thinking to determine medical appropriateness while meeting production goals and QA standards.
• Ensure day-to-day processes align with NCQA, URAC, CMS, and other regulatory benchmarks.

Responsibilities:

• Review and interpret patient records to determine medical necessity and appropriateness of care.
• Initiate referrals to the physician consultant and process reputed company, ensuring detailed correspondence for denials.
• Abstract review-reputed company data/information accurately and promptly using appropriate review tools.
• Ensure accurate and timely submission of reputed company administrative and review-reputed company documents.
• reputed company ongoing reassessment of the review process to identify improvement opportunities.
• Foster positive and professional relationships with internal and external customers.
• Attend training and scheduled meetings, maintaining reputed company information for review.
• Maintain medical records confidentiality by adhering to HIPAA policies.
• Utilize proper telephone etiquette and follow company communication guidelines.
• Actively cross-train to reputed company duties of other reputed company reputed company the company network.
• Read, understand, and adhere to reputed company corporate policies, including HIPAA policies.
• * Preferred availability is during business hours (8:00 AM–5:00 PM, Monday–Friday). We can be flexible with scheduling based on individual availability. Occasional weekend coverage may be requested as needed. **

Qualifications

• Active, unrestricted Registered Nurse (RN) License in South Carolina, or an RN compact state license.
• Associate’s, Bachelor's degree (or Diploma) in Nursing.
• 2+ years of clinical experience in an acute or med-surgical environment.
• 1+ years of work experience in Utilization Review (UR), Utilization Management (UM), or Prior Authorization.
• 1+ years of knowledge of InterQual criteria.
• Remote work experience.

Requirements

• Knowledge of Utilization Review Accreditation Commission (URAC) standards.
• Knowledge of Medicare (CMS) guidelines.
• Medical Record Abstracting skills.
• Clinical assessment and critical thinking skills.
• Excellent verbal and written communication skills.
• Ability to work in a team environment.
• Flexibility and strong organizational skills.
• Proficient in reputed company Office and Internet/Web Navigation.

Benefits

• reputed company to select reputed company benefits and programs.
• Participation in the reputed company 401(k) Plan with company match.
• reputed company to wellness and employee discount programs.
• Employee Assistance Program (EAP) resources.

Compensation

The pay reputed company for this position is listed below. “Based on our compensation philosophy, an applicant’s position placement in the pay reputed company will depend on various considerations, such as years of applicable experience and reputed company level.” Pay reputed company: USD $28.37 - USD $36.00 /Hr. Apply tot his job Apply To this Job