Clinical Review Nurse

Category:

Healthcare

Employment Type:

Contract

Reference:

BH-384302

Clinical Review Nurse (RN) (WORK FROM HOME)
needed for a remote
contract
opportunity with Yoh's client!
Top Skills You Should Possess:

• Minimum three years acute care clinical experience required
• Minimum two years of experience in appeals and grievances casework required

• 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.

• Active California Registered RN license required.
• Bachelor's degree preferred
• Minimum three years acute care clinical experience required
• Minimum two years of experience in appeals and grievances casework required
• Utilization Management or Quality Management experience preferred
• Experience using standardized clinical guidelines preferred
• Milliman Care Guidelines (MCG), Managed Care and NCQA experience preferred
• Have a cleared TB test prior to or within seven days of hire.
• Current CPR and first aid card prior to or within six months of hire is preferred.
• Excellent verbal and written communication skills.
• Ability to work within guidelines and protocols to achieve decisions independently.
• Excellent computer skills.

• Medical, Dental & Vision Benefits
• 401K Retirement Saving Plan
• Life & Disability Insurance
• Direct Deposit & weekly EPayroll
• Employee Discount Programs
• Referral Bonus Programs