Clinical Review Nurse

Fully Remote Clinical Review Registered Nurse

*MUST HAVE CA RN LICENSE*

We are looking for thoughtful, well rounded individuals looking to positively impact one of the TOP healthcare organizations!!

This is an incredible opportunity to gain phenomenal pay while simultaneously gaining medical training, knowledge, experience, and best of all MAKING A HUGE DIFFERENCE! In addition to a wonderful position there is HUGE opportunity for growth!

Principal responsibilities include:

• Conducts investigations and reviews of member and provider medical necessity grievances and appeals;
• Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity;
• Extrapolates and summarizes medical information for Medical Director, consultants or other external review;
• Apply clinical medical necessity guidelines, policy and procedures, and EOC benefit guidelines;
• Prepares recommendations to either uphold or overturn and forwards to Medical Director for approval;
• Ensures that appeals, grievances and disputes are resolved timely to meet regulatory requirements;
• Apply expedited criteria to recommend the appropriateness of urgent requests;
• Documents and logs appeal/grievance/dispute information on relevant tracking systems;
• Generates written correspondence to providers, members and regulatory entities;
• Interact with members, providers and/or other staff to ensure resolution of plan recommendations.
• Recognize potential quality of care concerns and refer to the Medical Director for review;
• Utilize leadership skills and serves as a subject matter expert for appeals/grievances/disputes/quality of care issues and is a resource for clinical and non clinical team members in expediting the resolution of outstanding issues.
• Perform other duties and special projects as assigned.

Essential Functions of the Job:

• Conducts investigations and reviews of member and provider medical necessity grievances and appeals, coding justifications, and provider disputes;
• Determine the appropriateness of care provided within the context of all applicable contractual requirements, state/federal regulations and accreditation standards;
• Identify system issues that result in failure to provide appropriate care to members or failure to meet service expectations and make recommendations for improvement;
• Perform writing, reporting, administration, and analysis; and
• Comply with the organization's Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.

Job Types: Full-time

Work Location/Schedule: M-F. 8-4:30 fully remote

Paid training provided.

Benefits:

• Competitive Salary
• Diverse culture
• Paid Holidays, Generous Leave (Sick and Vacation)
• 401K Retirement Plan
• Health Benefits, including medical, dental, vision, life and disability

Must Have Skills/Qualifications

• Active and unrestricted California Registered Nurse
• Minimum two years of experience in appeals and grievances casework required
• Strong knowledge of accreditation, federal and state regulations/requirements
• Detailed knowledge of managed healthcare and Evidence of Coverage (EOC), Medical coding knowledge
• Proficient in Microsoft Office suite including, Access and Project.

For California Applicants:

We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO) , and the California Fair Chance Act (CFCA).

This position is subject to a background check based on its job duties, which may include patient care, working with vulnerable populations, access to financial and confidential information, driving, working with heavy machinery, or working in a warehouse or laboratory environment. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.