[Hiring] Clinical Review Nurse @American Recruiting & Consulting Group

Role Description

The Clinical Review Nurse is responsible for reviewing and making medical determinations as to the validity of health claims and levels of payment in meeting national and local policies as well as accepted medical standards of care. The incumbent applies clinical knowledge to assess the medical necessity, level of services and appropriateness of care which may include cases requiring prior authorization, complex pre-payment medical review or post-payment medical review.

Essential Duties & Responsibilities

• 90% of time will be spent on one or more of the following activities depending on assignments:
  • Review and analyze pre and post pay complex health care claims from a medical perspective, inclusive of prior authorization.
  • Perform clinical review work as assigned; may provide guidance to other team members and accurately interpret and apply broad CMS guidelines to specific and highly variable situations.
  • Conduct review of claim data and medical records to make clinical decisions on the coverage, medical necessity, utilization and appropriateness of care per national and local policies, as well as accepted medical standards of care.
  • Review provider practices and identify issues of concern, overpayment and need for corrective action as necessary; includes surfacing potential fraud and abuse or practice concerns.
  • May develop recommendations for further corrective action based on medical review findings.
  • May refer for review, or implement, corrective action related to medical review activities.
  • May process claims and complete project work in the appropriate computer system(s).
• The remaining 10% of time will be spent on the following activities depending on assignments:
  • Identify providers needing education and individually educate providers who are subject to medical review processes.
  • Initiate or participate in provider teaching activities, creating written teaching material, providing one on one education or education to a group as a result of a medical review (e.g., probe, progressive corrective action, consent, etc.) or appeal.
  • This may involve discussion with CMS leaders and leaders in the provider community.
  • Participate in special projects as assigned.

Qualifications

• Valid nursing degree
• 2 years' clinical experience
• Excellent written and oral communication skills
• Demonstrated experience with evaluating medical and health care delivery issues (e.g., Inpatient Rehab Facility)
• Strong computer skills to include Microsoft Office proficiency
• Valid unrestricted Registered Nurse (RN) license

Preferred Qualifications

• Inpatient Rehabilitation Facility Experience
• Bachelor of Science in Nursing (BSN)
• Insurance industry experience
• Certified Coder

Benefits

• 100% remote positions
• Direct hire FTE positions with salary and benefits