Nurse Reviewer Associate- Remote

Summary

We are seeking a talented individual for the Nurse Reviewer, Associate position. In this role, you will perform clinical reviews to determine whether medical record documentation supports the need for a service, based on clinical criteria, coverage policies, and utilization and practice guidelines as defined by the review methodologies specific to the contract. This involves accessing proprietary systems to audit medical records, accurately documenting findings, and providing policy and regulatory support for determinations.

Essential Job Functions

• Review and interpret medical records, comparing them against criteria to determine the appropriateness and reasonableness of care. Apply critical thinking and decision-making skills to assess whether the documentation supports the need for the service while maintaining production goals and quality standards.
• Document decisions and rationale to justify review findings or no findings.
• Determine approvals or initiate referrals to the physician consultant, processing their decisions while ensuring denials are explained in sufficient detail and completed within contractual deadlines.
• Perform prior authorization, precertification, and retrospective reviews, and prepare decision letters as needed in support of the utilization review contract.
• Maintain current knowledge of clinical criteria guidelines and complete required CEUs to maintain RN licensure.
• Attend training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations.
• Actively cross-train to perform reviews of multiple claim types, providing a flexible workforce to meet client needs.

What we're looking for

• Active, unrestricted RN licensure from the United States and in your state of primary residence; an active compact multistate RN license as defined by the Nurse Licensure Compact (NLC) is also required.
• 3+ years of clinical experience in an inpatient hospital setting.
• 1+ years of experience in utilization review or claims auditing.
• Experience using Milliman or InterQual criteria is preferred.
• Demonstrated proficiency in computer skills, including Microsoft Windows, Outlook, Excel, Word, PowerPoint, internet browsers, and typing.

What you should expect in this role

• Home-based position; you must have a work location within the continental U.S.
• Must provide a high-speed internet connection and a work environment free from distractions.
• Full-time schedule during normal business hours is required, as the role involves frequent interactions with the team and other departments.
• May be required to work extended hours for special business needs.
• May be required to travel up to 10% of the time based on business needs.

This position is for pipeline purposes, and we welcome applications on an ongoing basis.