Clinical Review Nurse - Concurrent Review - J00933

Location: 100% Remote – Any US State

Shift: Tuesday - Thursday 9:30 am – 6 pm CST
Overtime may be required and Holidays are required

Duration: 12 Month contract ONLY ( No extensions or conversions at this time)

Description: Job Profile Summary
Drafts correspondence letters based on review outcomes in accordance with National Committee for Quality Assurance (NCQA) standards. Works with senior management to identify and implement opportunities for improvement.

• Performs clinical review of outcomes including creating and editing denial letters with the correspondence team based on denial determinations in accordance with National Committee for Quality Assurance (NCQA) standards
• Contributes to correspondence letter template creation and maintenance with the correspondence team
• Investigates denials through comprehensive review of clinical documentation, clinical criteria/guidelines, and policy, including insurance rejections due to coding issues and provides supplemental information to resolve denial claims
• Assists with issues and/or questions related to correspondence with the state, local, and federal agencies including third party payer to ensure issues are resolved in a timely manner
• Maintains and monitors cases to ensure timely resolution and logs of actions and/or decisions are appropriately documented
• Coordinates with interdepartmental teams on training needed within the utilization management team based on trends
• Provides feedback to leadership to improve clinical processes and procedures to prevent recurrences based on industry best practices
• Performs other duties as assigned
• Complies with all policies and standards

Typical Day in the Role: Working within a highly engaged team remotely, with ongoing support to produce denial correspondence based off the advisor review that is in easy-to-understand language to the member and adheres to the NCQA and state standards. There may be at times, OT expectations based on business needs. This team does work holidays, which are rotated amongst the team members

This candidate will be working with the IL and MI Medicaid product Correspondence Team is part Shared Services, which oversees many markets and states. The purpose of the team is to ensure that the members and requesting providers receive the written documentation of a denied service. Candidate may live anywhere in the U.S.

Candidate Requirements
Education/Certification	Required: Requires graduated from an accredited school of nursing or A.D. or bachelor’s in nursing			Preferred: 2-4 years of related experience
Licensure	Required: LPN or RN, active in any state			Preferred: Compact
Years of experience required: Must haves: Minimum 1 year nursing experience. Live anywhere in the U.S. Nice to haves: Knowledge of Medicare and Medicaid regulations; Knowledge of utilization management Disqualifiers: Performance indicators: Metric driven in production and quality
Top 3 must-have hard skills stack-ranked by importance		1	Ability to critically think
		2	Ability to effectively use Microsoft OneNote and Word
		3	Ability to work remotely, i.e. meet production deadlines; quality metrics