Remote Clinical Nurse Reviewer — Quality & Compliance

COMMENCE; Virginia Beach (VA); A distancia; USD 85.000 - 110.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Remote work

Descripción de la vacante

COMMENCE is seeking a Clinical Nurse Reviewer to evaluate medical records, treatment plans, and care quality for regulatory compliance in a remote role. You will leverage your RN license and clinical experience to assess medical necessity, support appropriate care, and document findings in EHR systems.

Stay current with InterQual / Milliman / CMS guidelines to drive quality assurance. Ideal candidates have 2–3 years of clinical experience in case management, utilization review, or QA, with

Formación

• Active RN license (state-specific)
• BSN preferred
• 2–3 years clinical experience, ideal in case management/utilization review/quality assurance
• Familiarity with ICD/CPT and insurance protocols
• Proficiency in medical terminology, HIPAA, and QA processes
• Strong attention to detail to review medical records accurately

Responsabilidades

• Review and analyze patient medical records, ensuring accuracy and regulatory compliance.
• Assess quality and appropriateness of care, identifying areas for improvement.
• Ensure proper documentation of diagnosis, treatment plans, and progress notes in protocols.
• Stay updated on healthcare regulations and guidelines; ensure practices align with requirements.
• Assess medical necessity and appropriateness of procedures and services.
• Conduct peer reviews to ensure quality and regulatory compliance.
• Provide recommendations for coverage determinations and appeals.
• Document findings in patient management systems.
• Stay current with clinical guidelines (InterQual, Milliman, CMS).

Conocimientos

Attention to detail

Analytical thinking

Medical terminology

Communication skills

HIPAA knowledge

Educación

RN license (state-specific)

BSN preferred

Herramientas

EHR systems

Microsoft Office

ICD/CPT familiarity

Descripción del empleo

COMMENCE is seeking a Clinical Nurse Reviewer to evaluate medical records, treatment plans, and care quality for regulatory compliance in a remote role. You will leverage your RN license and clinical experience to assess medical necessity, support appropriate care, and document findings in EHR systems.

Stay current with InterQual / Milliman / CMS guidelines to drive quality assurance. Ideal candidates have 2–3 years of clinical experience in case management, utilization review, or QA, with