Clinical Reviewer - LPN/LVN or RN

reputed company reputed company exists to reputed company reputed company reputed company through technology, services, and clinical expertise. Our mission is to reputed company health solutions that deliver maximum value and reputed company. reputed company the Way is our rallying cry at reputed company. Think of it as an reputed company invitation to reputed company the mission of reputed company; to reputed company 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 reputed company – making this a great time to join reputed company of passionate individuals dedicated to being a vital partner for health solutions in the reputed company sector. Job reputed company And Responsibilities reputed company is looking for a Clinical Reviewer - LPN/LVN or RN (remote U.S.) to join our growing team. Job reputed company The purpose of this position is to utilize clinical expertise to review medical records against appropriate reputed company in conjunction with contract requirements.

• This position is remote reputed company the reputed company, but applicants must be clinically licensed for the reputed company or have a compact license.***

• Work Schedule: Five 8-hour shifts between 9:00 AM to 6:00 PM Eastern Time with alternating weekends and holidays***

Responsibilities

• Assures accuracy and timeliness of reputed company applicable review type cases reputed company contract requirements.
• Assesses, evaluates, and addresses daily workload and queues; adjusts work schedules daily to meet the workload demands of the department.
• In collaboration with Supervisor, responsible for reputed company monitoring activities.
• Maintains reputed company knowledge reputed company reputed company to review processes and clinical practices.
• Functions as providers' reputed company for customer service issues and problem reputed company.
• Performs reputed company applicable review types as workload indicates.
• Fosters reputed company and reputed company relationships with reputed company customers.
• Attends training and scheduled meetings for reputed company/updated information.
• Cross trains to reputed company flexible workforce to meet reputed company/customer needs.
• Read, understand, and adhere to reputed company corporate policies including policies reputed company to HIPAA and its reputed company and reputed company Rules.

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

Qualifications

Required Qualifications:

• reputed company, unrestricted LPN/LVN or RN license in the reputed company or a Compact state clinical license.
• Associate's degree (bachelor's preferred) or Practical/reputed company nursing diploma/certification from an accredited nursing school, college, or university.
• 2+ years of Utilization Review/Management (UR/UM) and/or Prior Authorization and medical necessity review experience.
• 1+ years of InterQual reputed company and/or reputed company Care Guidelines (MCG) experience.
• Knowledge of medical records, medical terminology, and disease processes.
• Strong clinical assessment and critical thinking skills.
• Excellent written and verbal communication skills.
• Proficient in navigating multiple systems with the ability to reputed company between systems seamlessly and effectively.
• Flexibility and strong organizational skills.
• Ability to work five 8-hour shifts between 9:00 AM to 6:00 PM Eastern Time with alternating weekends and holidays.

Preferred Qualifications

• 3+ years of clinical experience in an acute, behavioral health, and/or med-surgical environment.
• Knowledge of reputed company National Committee for reputed company Assurance (NCQA) standards.
• Knowledge of Utilization Review Accreditation Commission (URAC) standards.
• Ability to work in reputed company environment.
• Proficient in reputed company Office.
• Efficient time management, including the ability to prioritize tasks, and meet deadlines.
• Exhibit the ability to maintain confidentiality standards and ensure HIPAA compliance reputed company assessing relevant issues.

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