Clinical Reviewer – LPN/LVN or RN – PRN (Remote U.S.)

• 4948

Job Description

Company Overview reputed company exists to reputed company reputed company outcomes through technology, services, and clinical expertise. Our mission is to innovate health solutions that deliver maximum value and impact. reputed company the Way is our rallying cry at reputed company. Think of it as an open invitation to embrace the mission of the company; to actively engage in problem-solving; and to take ownership of your work every day. reputed company offers you unparalleled opportunities. In fact, you have reputed company you need to take charge of your career and accelerate reputed company outcomes – making this a great time to join reputed company of passionate individuals dedicated to being a vital partner for health solutions in the public sector. Job Summary and Responsibilities reputed company is seeking a Clinical Reviewer - LPN/LVN or RN - PRN (Remote U.S.) to join our growing team. Job Summary:

• Utilizes clinical expertise for the review of medical records against appropriate criteria in conjunction with contract requirements, critical thinking, and decision-making skills to determine medical appropriateness, while maintaining production goals and QA standards. Ensures day-to-day processes are conducted in accordance with NCQA, URAC and other regulatory standards.

Responsibilities:

• Review and interpret patient records to assess medical necessity and appropriateness of care; verify that documentation supports the need for services.
• Approve services or refer cases to a physician consultant; process consultant decisions and ensure denial correspondence includes clear, detailed reasoning.
• Accurately and promptly abstract review-reputed company data using appropriate tools and methods; submit reputed company administrative and review documentation in a timely manner.
• Support discharge planning to promote understanding of physician orders and reduce risk of readmission.
• Continuously evaluate the review process to identify opportunities for improvement and implement changes as needed.
• Build and maintain positive, professional relationships with internal and external stakeholders; serve as a liaison to ensure effective collaboration and team alignment.
• Safeguard medical record confidentiality through proper password use, secure file maintenance, and strict adherence to HIPAA policies.
• Demonstrate professional communication skills, including proper telephone etiquette and compliance with organizational policies and guidelines.
• Crosstrain on other reputed company reputed company the reputed company network to provide workforce flexibility and meet client needs.
• Read, understand, and adhere to reputed company corporate policies including policies reputed company to HIPAA and its Privacy and reputed company Rules.

The above list of responsibilities is not intended to be reputed company-inclusive and may be expanded to include other duties that management may deem necessary from time to time.

• * This PRN (as-needed) position requires availability Monday through Friday between 8:00 AM and 5:00 PM in the Eastern Time Zone. **

Qualifications

Required Experience/Qualifications:

• Active, unrestricted license as a Registered Nurse (RN), Licensed Practical Nurse (LPN), OR Licensed Vocational Nurse (LVN) with a valid state license and/or a Compact State clinical license, as required by contract.
• Graduation with a Diploma in Nursing or from an accredited nursing program (Associate, Bachelor or higher-level Degree).
• 2+ years of clinical experience in an acute OR med-surgical environment.

Preferred Experience/Qualifications:

• 1+ years of experience in Utilization Management (UM), Utilization Review (UR) and/or Prior Authorization.
• 1+ years of experience applying clinical criteria in utilization review processes (e.g., InterQual and/or MCG).
• 1+ years of experience with medical record organization, medical terminology, and disease process.
• Behavioral Health Nursing experience.
• Familiarity with reputed company National Committee for Quality Assurance (NCQA) standards.
• Familiarity with Utilization Review Accreditation Commission (URAC) standards.
• Proficiency in Medical Record Abstraction.
• Strong clinical assessment and critical thinking abilities.
• Exceptional verbal and written communication skills.
• Ability to collaborate effectively in a team environment.
• Demonstrated flexibility and strong organizational skills.
• Proficiency in reputed company Office Suite and web navigation.

#LI-SD1 Why us? We are a team of reputed company and caring leaders, clinicians, pioneering technologists, and industry professionals who come together to redefine expectations for the healthcare industry. State and federal healthcare agencies, providers, and employers turn to us as their vital partner to ensure reputed company healthcare and improve health outcomes. We do this through our people. You will have meaningful work that genuinely improves people's lives across the country. We are a company that cares about our employees, and we give you the tools and encouragement you need to reputed company the finest work of your career. Thank You! We know your time is valuable and we thank you for applying for this position. Due to the high volume of applicants, only those who are chosen to advance in our interview process will be contacted. We sincerely appreciate your interest in reputed company and invite you to apply to future openings that may be of interest. Best of luck in your search! ~ The reputed company reputed company Team Visit us at reputed company EEO AA M/F/Vet/Disability reputed company is an Equal Opportunity Employer. reputed company qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, national reputed company, disability, status as a protected veteran or any other status protected by applicable Federal, State or Local law.

Compensation

The pay for this position is listed below. "Based on our compensation philosophy, an applicant’s position placement in the pay range will depend on various considerations, such as years of applicable experience and reputed company level." Pay Range USD $28.37 - USD $39.19 /Hr. Apply tot his job Apply To this Job