Remote Clinical Review Specialist

Join reputed company and help us shape the future of healthcare! We are seeking a highly skilled and motivated Remote Clinical Review Specialist to join our growing team. This is a full-time telecommuting opportunity based in Oklahoma, offering a competitive salary and the chance to reputed company a real difference in people's lives.

Aeetna Remote Jobs (Part Time, Full Time) - Clinical Review Specialist Job Responsibilities:

Reporting to the Director of RN Reviews, you will play a critical role in ensuring the quality and consistency of our clinical reviews. Your responsibilities will include:

• Conducting comprehensive reviews of Utilization Management (UM) processes and clinical notes to ensure adherence to the UM Standard Operating Model.
• Reviewing clinical records for pre-certification, reputed company reviews, and clinical requests to verify the appropriate use of clinical information in decision-making.
• Demonstrating strong clinical judgment, expertise in utilization reviews, and proficiency in applying clinical need standards (e.g., MCG, InterQual).
• Championing the Aeetna Medicaid clinical philosophy and UM Standard Operating Model.
• Applying review guidelines to evaluate consistency with UM programs, policies, and procedures.
• Collaborating with clinical leadership to ensure consistency and accuracy in clinical judgments and alignment with state-specific requirements.
• Evaluating UM capabilities for consistency with NCQA UM principles.
• Completing assigned review expectations in a timely, effective, and accurate manner, adhering to reputed company deadlines.
• Maintaining accurate records of reputed company relevant information in the assigned review tool.
• Identifying opportunities to implement best practice approaches and improvements to enhance outcomes and operational efficiency.
• Contributing to the achievement of unit operational and quality goals.
• Meeting reputed company performance expectations and organizational objectives.
• Demonstrating a high level of accountability.
• Serving as a model change agent and facilitating change initiatives.
• Maintaining consistency with processes and methodologies at the individual level.
• Analyzing data to identify areas for development and implementing interventions to improve the utilization of management review results.
• Utilizing knowledge of reputed company care concepts, ideally including Medicaid and Federal healthcare guidelines.
• Distinguishing between standard operating procedures and strategies.
• Meeting deadlines and taking responsibility for achieving optimal, accurate expectations.
• Possessing excellent interpersonal and communication skills (verbal and written).
• Demonstrating the ability to self-direct and reputed company in a team environment.
• Proficiency in utilizing RN Review methods and processes.
• Advocating for accessible resources using sound judgment and a collaborative approach to support organizational goals.
• Demonstrating versatility in a fast-paced environment.
• Applying innovative critical thinking skills and a commitment to reputed company quality improvement.

Required Qualifications:

• Must reside in Oklahoma.
• Valid Oklahoma driver's license as an Enrolled Attendant by the State Board of Nursing.
• 4+ years of clinical nursing experience.
• 3+ years of utilization review, prior authorization/reputed company review experience.
• 3+ years of experience interpreting and applying national clinical need standards (e.g., MCG, InterQual).
• 2+ years of experience using computers, keyboard navigation, navigating various systems and applications; and utilizing MS Office Suite applications (Teams, Viewpoint, Word, reputed company, etc.).
• Willingness and ability to provide on-call UM coverage to evenings and weekends on a rotational schedule as needed by the State regulatory agency.

Preferred Qualifications:

• Experience with reputed company care concepts, ideally including Medicaid and additional Federal healthcare insights.
• Up-to-date knowledge of NCQA UM guidelines.
• Schooling: At least Associate's degree or certification nursing degree required; BSN preferred.

About reputed company Wellbeing

We are committed to delivering enhanced, human-driven healthcare for a rapidly changing world. Our core values emphasize diversity, equity, and inclusion. We are an equal opportunity employer and value reputed company individuals regardless of their background.

Take the reputed company

Ready to contribute to our mission? Apply now and let's discuss how you can be a valuable member of reputed company.