Clinical Review Registered Nurse

TekWissen ®; United States; Remote; USD 70,000 - 85,000; Full time

Job summary

A leading healthcare organization is seeking a Clinical Review Registered Nurse to execute utilization management processes and ensure high-quality care through clinical reviews. This remote position requires strong knowledge of healthcare systems and excellent communication skills. The role involves reviewing requests for medical necessity, conducting audits, and collaborating with providers to enhance service delivery. Join a dynamic team committed to improving patient care and satisfaction.

Qualifications

• Expertise in clinical nursing practice.
• Strong knowledge of health insurance and regulatory standards.

Responsibilities

• Conduct clinical reviews of prior approvals and claims requests.
• Communicate with providers to obtain necessary clinical information.
• Perform monthly audits of prior approval processes.

Skills

Strong knowledge of healthcare delivery systems

Excellent written and oral communication skills

Strong analytical skills

Strong organizational skills

Strong interpersonal skills

Education

Registered Nurse

Tools

Microsoft Office

Salesforce Health Cloud

Jira

Job description

3 weeks ago Be among the first 25 applicants

Overview

TekWissen is a global workforce management provider headquartered in Ann Arbor, Michigan, offering strategic talent solutions worldwide. Our client is a health insurance company providing various health care coverage plans, including individual and family plans, dental and vision, and employer plans.

Title: Clinical Review Registered Nurse

Work Location: Vermont

Duration: 1-3 Months

Job Type: Contract

Work Type: Remote

Position Summary

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

Primary Responsibilities

• Conduct clinical reviews of all prior approvals, post-service reviews, customer service, and claim requests. Determine the adequacy of clinical information submitted and request additional information as needed. Make determinations based on medical policy, evidence-based guidelines, and medical necessity.
• Communicate directly with requesting providers to obtain additional clinical information necessary for utilization management decisions.
• Review late and out-of-network prior approval/referral authorizations for appropriateness and determine benefit levels based on medical necessity.
• Provide timely and accurate reviews for procedure/service appropriateness, reconsideration, and appeals based on applicable standards.
• Perform monthly audits of prior approval processes and weekly reviews to confirm medical necessity and appropriateness of services.
• Use sound clinical judgment along with review criteria and practice guidelines to confirm medical necessity and appropriateness.
• Support Provider Relations and Provider Reimbursement teams regarding clinical issues related to new procedures, coding, pricing, and provider communications.
• Refer cases to the medical director as appropriate and report any potential quality of care issues.
• Update case files in the appropriate systems promptly.
• Participate in medical policy development and research, collaborating with providers.
• Review health service delivery, utilization, and cost data.
• Identify members who may benefit from case management and initiate referrals for intervention.
• Determine member eligibility, coverage, and benefits, aiming to enhance member and provider satisfaction.
• Assist in the accurate adjudication of care management services during claims processing.

Competencies (Knowledge, Skills, and Abilities)

Subject Matter Expertise

• Strong knowledge of healthcare delivery systems, health insurance, medical practices, trends, regulatory standards, and provider network management.
• Comprehensive understanding of all plan products and benefits affecting clinical decision-making.
• Expertise in clinical nursing practice.

Computer Skills

• Proficient in Microsoft Office, CPT, HCPCS coding, ICD-10 diagnosis codes, and specialized applications like Salesforce Health Cloud, Acuity, Microsoft CRM, OnBase, Jira.

Communication Skills

• Excellent written and oral communication skills.

Interpersonal Skills

• Strong interpersonal skills.

Organizational Abilities

• Strong organizational skills.

Analytical Skills

• Strong analytical skills, including statistical data analysis.

TekWissen Group is an equal opportunity employer supporting workforce diversity. We are a global human capital, recruitment, and IT services organization operating since 2009, with a presence in six countries: United States, Canada, Australia, India, United Kingdom, and the Philippines. We specialize in tailored talent solutions and IT engagements.