Remote RN, Clinical Record Review

Managed Medical Review Organization; Eagle (ID); Remote; USD 70,000 - 95,000; Full time

Job summary

Managed Medical Review Organization is seeking a skilled registered nurse for a remote, home-office role. The position emphasizes telephonic/customer service, accurate documentation, and clinical review duties without face-to-face patient contact.

The role requires 12 pm–8 pm EST, Monday–Friday, with rotating on-call coverage on weekends/holidays. Remote work is supported, with residency in specified states and prior experience in insurance review essential.

Qualifications

• Current unrestricted RN state license.
• Graduate from an accredited School of Nursing with BSN or ADN.
• Strong computer and documentation skills.
• Minimum 2 years in healthcare insurance, appeals/grievances, UR or QA.
• Ability to work independently and maintain confidentiality.
• Effective communication with physicians, colleagues and clients.
• Strong verbal and written communication skills.
• Must be able to work 12 pm - 8 pm EST, Mon-Fri with rotating on-call weekends/holidays.

Responsibilities

• Verify conflicts of interest per policy.
• Review medical records and applicable review questions.
• Maintain communication with Physician Reviewer during review.
• Verify Physician Reviewer credentials per policy.
• Communicate delays with referring party as required.
• Discuss and review training material with Physician Reviewers.
• Maintain external reviews documentation per state requirements.
• Document all required case activities in W5.
• Input Physician Reviewer costs and client charges into W5.
• Quality review rough draft HCR reports for quality and compliance.
• Remediate quality issues identified with Physician Reviewer.
• Assist in selecting evidence-based criteria supporting rationale.
• Perform final review of HCR reports for client submission.
• Participate in orientation/training programs.
• Participate in Quality Improvement Committee/projects.
• Address ongoing quality issues with Quality Department.

Skills

Communication skills

Independent worker

Telehealth experience

Documentation accuracy

Education

RN license in good standing

BSN or ADN

Job description

Applicants must reside in: Michigan, Florida, Idaho, Texas, Minnesota or Illinois. Must be able to work 12 pm - 8 pm EST, Monday through Friday, with rotating on call coverage for weekends and holidays.

We are searching for a new RN to join our team. Our Nurses enjoy the flexibility to work remotely and do not have face-to-face Patient contact. This position is performed in a home-office environment and requires great telephonic/customer service and documentation skills in addition to clinical experience.

Please review the roles and responsibilities of this position below. Please complete all application questions and follow-up assessments. Incomplete applications will not be accepted.

Roles and responsibilities

• Upon receipt of a case, verify the presence of any real or perceived conflict of interest, consistent with corporate policy (Ref: Policy and Procedure- Conflict of Interest).
• As applicable, based on the HCR service type requested, review medical records for completeness, verify the appropriate service, Physician Reviewer Specialty, and appropriate review questions upon review of the case
• Maintain communication with the Physician Reviewer (as applicable) during the review process to ensure timely and accurate delivery of the review service being completed.
• Verifies current credentials for the Physician Reviewer. Verify that credentialing has not expired and is completely consistent with corporate policy (Ref: MMRO Credentialing Policy & Procedure).
• Maintain communication, including but not limited to any delays in service, with the referring party as required for the case type being performed.
• As applicable, discuss and review training material with Physician Reviewers.
• Maintain policy and process requirements for State Mandated External Reviews, including the submission of all required correspondence and documentation consistent with state requirements.
• Accurately and consistently document all required case activities in W5.
• Accurately inputs Physician Reviewer cost and client charge into W5 for invoicing/payment by the Bookkeeper.
• Quality review rough draft versions of HCR reports to ensure clinical quality and compliance, including but not limited to: clinical quality issues (i.e. clinical substantiation, clinical inconsistences, plan language compliance) incomplete reports, report inconsistencies, and grammar or typographical errors.
• Communicate, verbally or in writing, with the Physician Reviewer, to remediate any quality issues identified, consistent with corporate policy.
• Assist the Physician Reviewer, as applicable, in selecting and utilizing evidence-based criteria and support of clinical rationale.
• Perform final review of HCR reports in preparation of submitting to client.
• As applicable, participate in Physician Reviewer orientation/training programs, including the development of customized or individualized physician orientation and training programs.
• As applicable, participate in the Quality Improvement Committee and/or participate in Quality Improvement Projects, as requested by the Quality Department.
• Address ongoing quality issues with the Quality Department and suggest quality improvement initiatives, as deemed appropriate.

Required Qualifications and Education

• Current unrestricted RN state license
• Graduate from an accredited School of Nursing, approved by the applicable state Board of Nursing. Degree shall include a Bachelor of Science in Nursing (B.S.N.) or Associate Degree in Nursing (A.D.N.)
• Thorough knowledge of computer operation and software applications related to work performed
• A minimum of two (2) years related experience, specifically in the healthcare insurance industry, preferably in the capacity of Appeals/Grievances, Case Management, Utilization Review or Quality Assurance Specialist.
• Ability to work independently and maintain confidentiality
• Ability to communicate effectively and work co-operatively with Physician Reviewers, co-workers and clients
• Strong verbal and written communication skills
• Familiarity with MLA, NLM, and other citation standards
• Self-directed with positive attitude
• Must be able to work 12 pm - 8 pm EST, Monday through Friday, with rotating on call coverage for weekends and holidays.