Clinical Review Registered Nurse

Strategic Staffing Solutions; Burlington (VT); Remote; USD 70,000 - 90,000; Full time

Job summary

Strategic Staffing Solutions is seeking a Clinical Review Registered Nurse for a short-term W2 contract position in Vermont. The role involves executing utilization management processes to ensure cost-effective healthcare through clinical reviews, making critical approvals based on medical necessity and evidence-based practices. Ideal candidates should possess extensive clinical experience and a passion for quality patient care.

Qualifications

• 5+ years of clinical/hospital experience as a RN.
• Must have a Compact Nursing License.
• 2+ years of Utilization Review/Management experience.

Responsibilities

• Conduct clinical reviews for prior approval and claim requests.
• Make determinations based on medical policies and guidelines.
• Provide support to Provider Relations regarding clinical issues.

Skills

Clinical Judgement

Communication

Utilization Management

Job description

STRATEGIC STAFFING SOLUTIONS (S3) HAS AN OPENING!

Strategic Staffing Solutions is currently looking for a Clinical Review RN for a contract opportunity with one of our largest clients located in Vermont!

Title: Clinical Review Registered Nurse
Duration: W2 Contract
Location: Remote in Vermont
Duration: 3 Month – short term assignment

Position Summary:
This position executes utilization management processes to ensure the delivery of medically necessary and appropriate, cost-effective and high-quality care through the performance of clinical reviews. Reviews requests against standardized medical necessity and appropriateness criteria for an initial and a continued service authorization. Identifies questionable cases and refers to superior or a medical director for review.’

Required experience:

• Must have 5+ years of clinical/hospital experience as a RN
• Must have a Compact Nursing License.
• Must bring 2+ years of Utilization Review/Management experience.

Primary Responsibilities:

• Conduct clinical reviews of all prior approval, post-service reviews, customer service and claim requests.
• Determine adequacy of clinical elements of clinical information submitted. Determine essential elements of clinical information for decision-making and request same as appropriate. Make determinations based on medical policy, evidence-based guidelines, and medical necessity.
• Communicate directly with requesting providers to obtain additional clinical information as needed in order to make utilization management decisions.
• Review late and out of network prior approval / referral authorizations for appropriateness and make determination on benefit level based on medical necessity.
• Provide timely and accurate review for procedure/service appropriateness, reconsideration, and appeals based on Rule 9-03, DRF, and NCQA Standards.
• Perform monthly audits related to prior approval processes as well as weekly guidelines to confirm medical necessity and appropriateness of reviewed services.
• Use sound clinical judgment along with appropriate review criteria and practice guidelines to confirm medical necessity and appropriateness of reviewed services.
• Provide support to Provider Relations and Provider Reimbursement in regard to clinical issues relating to new procedure, coding, pricing and provider communications.
• Provide appropriate and timely referrals to the medical director. Identify and report any potential quality of care of services issue to the medical director.
• Perform timely case review information, case entry and updates to case file in the appropriate systems.
• Participate in medical policy committee including research and development of policies and collaboration with participating provider.
• Assist in review of health service delivery and utilization and cost data.
• Assist the claims payer in accurate adjudication of care management approved services as needed.

*Beware of scams. S3 never asks for money during its onboarding process

Job ID: JOB-241276
Publish Date: 29 Apr 2025

Tagged as: Clinical Review Registered Nurse