Senior Professional Nurse

Summary

We are seeking a highly skilled and experienced Senior Professional Nurse to join our team in a hybrid role. This position involves conducting clinical reviews to assess whether medical documentation supports the necessity of services, based on established clinical criteria, coverage policies, and contract-specific review methodologies. The role requires auditing medical records using proprietary systems, documenting findings accurately, and applying regulatory and policy knowledge to support determinations.

Key Responsibilities

• Conduct thorough reviews of medical documentation to evaluate the appropriateness and necessity of care using clinical criteria and critical thinking.
• Document review outcomes and provide clear, concise rationales for findings or non-findings.
• Refer cases to physician consultants when necessary and ensure detailed, timely documentation of denial reasons in accordance with contract deadlines.
• Support management in onboarding and training new Nurse Reviewers through mentoring, monitoring, and education.
• Stay current with clinical guidelines and complete required continuing education units (CEUs) to maintain RN licensure.
• Participate in training sessions and meetings to enhance understanding of clinical policies, procedures, and regulations.
• Cross-train across multiple claim types to support a flexible and responsive workforce.
• Recommend and implement process improvements, audit innovations, and technology enhancements to boost productivity, quality, and client satisfaction.

Required Knowledge, Skills, and Abilities

• Strong analytical skills to evaluate medical information and apply clinical guidelines effectively.
• Proven experience in medical review, chart auditing, and quality improvement.
• Excellent written communication skills with the ability to produce clear and accurate rationales.
• Familiarity with HIPAA Privacy and Security regulations.
• Ability to manage multiple tasks in a fast-paced, production-driven environment.
• Strong interpersonal skills for building internal and external relationships.
• Proficiency in Microsoft Office Suite and internet browsers.
• Experience with virtual collaboration tools such as Microsoft Teams and Zoom.

Work Conditions and Physical Requirements

• Hybrid work model: primarily remote with occasional in-person attendance for account meetings.
• Must reside within the continental United States.
• Reliable high-speed internet and a distraction-free home workspace are required.
• Standard business hours with frequent team and departmental interactions.
• Sedentary office work with occasional standing, walking, and lifting (up to 10 lbs).
• Manual dexterity for computer and phone use.
• Occasional extended hours may be required for business needs.
• Travel may be required up to 10% based on business demands.

Qualifications

• Active, unrestricted RN license (Bachelor’s degree in Nursing preferred).
• Minimum of 5 years clinical experience in an inpatient hospital setting.
• At least 2 years of experience in utilization review or claims auditing (preferred).
• Familiarity with Milliman or InterQual criteria (preferred).
• Knowledge of HCPCS and ICD coding, reimbursement systems, benefit coverage, medical policy, and relevant federal and state regulations.

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