Clinical Reviewer

Job Summary and Responsibilities

The purpose of this position is to review medical records against appropriate criteria in conjunction with contract requirements to determine medical appropriateness. This is a remote position. The selected candidate will typically work Monday-Friday from 8:00 AM - 5:00 PM Eastern AND from 10:00 AM - 7:00 PM Eastern one day, every other week, as assigned.

• Affirms accuracy and timeliness of all applicable review-type cases within contract requirements.
• Affirms assessments, evaluations, and addresses daily workload and queues; adjusts work schedules daily to meet the workload demands of the department.
• Collaborates with supervisor to monitor quality activities, including identifying areas of improvement and implementing improvement areas.
• Maintains current knowledgebase related to review processes and clinical practices related to the review processes, functioning as the internal resource to nurse reviewers regarding all review process questions and/or concerns.
• Fosters positive and professional relationships and liaises with internal and external customers to ensure effective working relationships and team building to facilitate the review process.
• Attends training and scheduled meetings for maintenance and use of current/updated information for review.
• Cross-trains and performs duties of other contracts to provide a flexible workforce to meet client/customer needs.
• Reads, understands, and adheres to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.

Qualifications

• Active, unrestricted Licensed Practical Nurse (LPN) license, Licensed Vocational Nurse (LVN) license, or Registered Nurse (RN) license from the state where you reside, per contract/state requirements.
• Associate's degree or practical/vocational nursing diploma or nursing certificate program, in accordance with state requirements.
• Medical record abstracting skills, including knowledge of medical record organization, medical terminology, and disease processes.
• Strong clinical assessment and critical thinking skills.
• Will typically work Monday-Friday from 8:00 AM - 5:00 PM Eastern AND from 10:00 AM - 7:00 PM Eastern one day, every other week, as assigned.

Preferred Qualifications

• Bachelor's Degree from an accredited college or university in a related field.
• 1+ years Utilization Management/Utilization Review.
• 1+ years Private Duty Nursing OR Home Health experience.
• Excellent written and verbal communication skills.

Benefits

• Comprehensive health plans
• Paid time off
• Retirement savings
• Corporate wellness
• Education assistance
• Corporate discounts

Pay Range

USD $28.37 - USD $35.00 /Hr.