Nurse Reviewer I

About the role

This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office.

Schedule

Monday – Friday, 11:30 am to 8:00 pm (CST) and Alternating Weekends, 8:00 am to 12:00 pm (CST).

Responsibilities

• Conduct initial medical necessity review of exception preauthorization requests for services requested outside of the client health plan network.
• Follow-up to obtain additional clinical information.
• Ensure proper documentation, provider communication, and telephone service per department standards and performance metrics.
• Validate appeal requests.
• Manage appeal requests that come via email, fax, mailed in letters, or via live line.
• Open and close appeal requests following established appeal processes to maintain quality, turnaround time, and compliance requirements.
• Outreach to providers with appeal process instructions.
• Perform clinical review for the RBM and Surgical solution on a client specific basis.
• Notify providers and/or members of appeal decisions.
• Maintain log of all appeal requests assigned to ensure completion, as needed.

Qualifications

• AS in nursing and minimum of 3 years of clinical nursing experience in an ambulatory or hospital setting OR minimum of 1 year of prior utilization management, medical management and/or quality management, and/or call center experience; or any combination of education and experience, which would provide an equivalent background.
• Current, unrestricted RN license in either Illinois and/or California is required.

Skills

• Familiarity with Utilization Management Guidelines, ICD-9 and CPT-4 coding, and managed health care including HMO, PO and POS plans strongly preferred.
• BA/BS degree preferred.
• Previous utilization and/or quality management and/or call center experience preferred.

Pay

$35.54/hr. to $55.73/hr. for candidates working in California or Illinois.

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase and 401k contribution