Clinical Review Nurse (REMOTE for AZ/CA/TX/NV)

Clinical Review Nurse (Remote for AZ/CA/TX/NV)

Job Details

Posting Date: 03-25-25

Reference ID: 240544

Location: Alameda, CA

Work Location: Remote ONLY for candidates located in AZ, CA, TX or NV **Must have Active RN License in CA

Discipline: Nursing and Insurance (Managed Care)

Job Type: Contract (6 Month Duration) with potential for FTE

Salary Expectations/ Pay Rate or Range: $52.00-$63.00 per hour

Job Description

Responsibilities/ Job Duties: The Clinical Review Nurse is responsible for investigating and processing comprehensive and complex grievances and appeals requests from members and providers, coding justifications, and provider disputes. This position identifies through clinical review any system or processing issues that resulted in failure to provide appropriate care to members, failure to meet service expectations, billing concerns, and provider disputes. The Clinical Review Nurse has a dotted-line reporting relationship to the Chief Medical Officer.

• 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 the 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 serve 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.

Minimum Education and Experience Qualification Requirements:

• Active and Unrestricted CALIFORNIA Nursing License
• Minimum 2+ Years of Experience in Appeals & 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
• Experience with Medi-Cal HIGHLY Preferred, though not required

Schedule/ Shift: M-F, 8am-5pm PST **regardless of residing state (i.e. if candidate is in TX they must align to PST hours)

Benefits:

• Paid Sick Leave (Medix provides paid sick leave according to state and local sick leave ordinances)

• Health Benefits / Dental / Vision (Medix Offers 6 different health plans: 3 Major Medical Plans, 2 Fixed Indemnity Plans (Standard and Preferred), and 1 Minimum Essential Coverage (MEC) Plan. Eligibility for health benefits is based on verifying that an average of 30 hours per week during the first 4 weeks of the work assignment has been met. If you meet eligibility requirements and take action to enroll, you will be covered no earlier than 60 days into your assignment, depending on plan selection(s).)

• 401k (eligible on the first 401k open enrollment date following 6 consecutive months on assignment. 401k Open Enrollment dates are 1/1, 4/1, 7/1, and 10/1)

• Short Term Disability Insurance

• Term Life Insurance Plan

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.

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.