Nurse Reviewer- Registered Nurse (Remote)

Summary

We are seeking a talented individual for a Nurse Reviewer (RN) who will be responsible for performing clinical reviews to determine if the medical record documentation supports the need for the service based on clinical criteria, coverage policies, and utilization and practice guidelines as defined by review methodologies specific to the contract for which services are being provided. This involves accessing proprietary systems to audit medical records, accurately documenting findings, and providing policy/regulatory support for determinations.

This position is intended for pipelining. We will accept applications on an ongoing basis.

Your role in our mission

• Review and interpret medical records and compare them against criteria to determine appropriateness and reasonableness of care. Apply critical thinking and decision-making skills to assess if 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 approval or initiate a referral to the physician consultant, and process physician consultant decisions—ensuring the denial rationale is clearly detailed and completed within the contractual deadline.
• Perform prior authorization, precertification, and retrospective reviews; prepare decision letters as needed in support of the utilization review contract.
• Assist management with training new Nurse Reviewers, including daily monitoring, mentoring, feedback, and education.
• Maintain up-to-date knowledge of clinical criteria guidelines and complete required CEUs to maintain RN licensure.
• Attend training and scheduled meetings to strengthen working knowledge of clinical policies, procedures, rules, and regulations.
• Cross-train to perform reviews of multiple claim types to ensure workforce flexibility and meet client needs.
• Recommend, test, and help implement process improvements, audit concepts, and technology enhancements that increase productivity, quality, and client satisfaction.

What we're looking for

• Proficiency in computer and typing skills (e.g., Microsoft Windows, Outlook, Excel, Word, PowerPoint, and internet browsers).
• Active, unrestricted RN license from the United States and in the state of primary home residency. An active compact multistate unrestricted RN license (as defined by the Nurse Licensure Compact – NLC) is required and will be verified during the post-offer background check.
• Minimum of 5 years clinical experience in an inpatient hospital setting.
• At least 2 years of utilization review or claims auditing experience.
• Experience using Milliman or InterQual criteria is required.
• Ability to work standard business hours, as this role involves regular interactions with internal teams and other departments.
• May occasionally require extended hours to meet business needs.

What you should expect in this role

• This is a full-time job.
• Health benefits (medical, dental, vision) and paid time off begin on Day 1 of employment.
• Company-provided computer.
• Remote/work-from-home role; employees must be located within the continental U.S.
• Home workspace must be quiet, secure, free from distractions and recording devices.
• May require up to 10% travel, depending on business needs.

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