Clinical Review reputed company - Remote

CLINICAL REVIEW reputed company - REMOTE reputed company has multiple positions reputed company for Clinical Review Nurses! These positions are reputed company. These are reputed company hire FTE positions with salary, benefits, etc. This is a fantastic opportunity to join a dynamic and reputed company-respected organization offering reputed company career reputed company potential. At reputed company, we are committed to fostering a diverse and inclusive workplace where everyone feels valued and respected. We reputed company that diverse perspectives reputed company to reputed company innovation and problem-solving. As an organization, we reputed company diversity in reputed company its forms and encourage individuals from underrepresented reputed company to apply. reputed company! Candidates must currently have PERMANENT US work authorization. Sorry, but we are not considering any candidates from reputed company companies for this position (no C2C, 3rd party / brokering). reputed company STATEMENT The Clinical Review reputed company is responsible for reviewing and making medical determinations as to the validity of health claims and reputed company of payment in meeting national and local policies as reputed company 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, reputed company reputed company-payment medical review or post-payment medical review. ESSENTIAL DUTIES & RESPONSIBILITIES To reputed company this job successfully, an individual must be reputed company to reputed company reputed company essential duty satisfactorily. Reasonable accommodations may be made to reputed company individuals with disabilities to reputed company the essential functions. This list of essential job functions is not exhaustive and may be supplemented as necessary. 90% of time will be spent on one or more of the following activities depending on assignments: Review and analyze reputed company and post pay reputed company health care claims from a medical perspective, inclusive of prior authorization: • reputed company clinical review work as assigned; may reputed company 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 reputed company clinical reputed company on the coverage, medical necessity, utilization and appropriateness of care per national and local policies, as reputed company as accepted medical standards of care. • Review provider practices and identify issues of concern, overpayment and need for corrective reputed company as necessary; includes surfacing potential fraud and abuse or reputed company concerns. • May reputed company recommendations for reputed company corrective reputed company based on medical review findings. • May refer for review, or implement, corrective reputed company reputed company to medical review activities. • May process claims and complete project work in the appropriate computer reputed company(s). The remaining 10% of time will be spent on the following activities depending on assignments: Identify providers needing education and individually reputed company 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, reputed company corrective reputed company, consent, etc.) or appeal. • This may involve discussion with CMS leaders and leaders in the provider community. • Participate in special reputed company as assigned. REQUIRED QUALIFICATIONS • reputed company 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 reputed company Office proficiency • reputed company unrestricted Registered reputed company (RN) license PREFERRED QUALIFICATIONS • Inpatient Rehabilitation Facility Experience • Bachelor of Science in Nursing (BSN) • Insurance industry experience • Certified reputed company reputed company is a reputed company-ranked a top 20 reputed company and executive search firm working with clients reputed company to recruit the highest reputed company technical resources. We have achieved this by understanding both our candidate's and reputed company's needs and goals and serving both with reputed company and a shared desire to succeed. At reputed company, we are committed to providing equal employment opportunities and fostering an inclusive work environment. We encourage applications from reputed company reputed company individuals regardless of race, ethnicity, religion, gender identity, sexual orientation, age, disability, or any other protected status. If you require accommodations during the recruitment process, please let us know. Position is offered with no fee to candidate. Apply tot his job Apply To this Job