Job Description

Job Description

Job Description

Job Summary

The purpose of this position is to utilize clinical expertise to review medical records against established criteria in accordance with contract requirements.

Location: Remote (U.S.-based)
Licensure Requirement: Must hold an active clinical license in the State of Indiana or a Compact State license

Work Schedule:

• Up to 25 hours per week
• Weekend and/or holiday availability required based on business needs

Training Requirement:

• Must be fully available to attend 100% of training
• Schedule:  Monday–Friday, 9:00 AM – 6:00 PM EST
• Duration:  Minimum of 3 weeks

• Ensure accuracy and timeliness of all review cases in accordance with contract requirements
• Manage daily workload and queues; adjust workflow as needed to meet departmental demands
• Collaborate with Supervisor on quality monitoring and improvement activities
• Maintain current knowledge of clinical practices and review processes
• Serve as a liaison for providers regarding customer service issues and resolution
• Perform various review types as assigned based on workload
• Build and maintain professional relationships with internal and external stakeholders
• Attend required trainings and team meetings
• Cross-train to support business and client needs
• Comply with all corporate policies, including HIPAA Privacy and Security regulations

Note: Responsibilities may evolve based on business needs.

 

• Active, unrestricted  LPN/LVN or RN license in Indiana or Compact State
• Associate’s degree (Bachelor’s preferred) or diploma from an accredited nursing program
• 2+ years of Utilization Review/Management (UR/UM) and/or Prior Authorization experience
• 2+ years of medical necessity review experience
• 1+ year of InterQual and/or Milliman Care Guidelines (MCG) experience
• Strong knowledge of medical records, terminology, and disease processes
• Excellent clinical assessment and critical thinking skills
• Strong written and verbal communication skills
• Ability to navigate multiple systems efficiently
• Strong organizational skills and flexibility

• 3+ years of clinical experience (acute care, behavioral health, and/or med-surgical)
• Knowledge of  NCQA and URAC standards
• Experience working in a team-based environment
• Proficiency in  Microsoft Office
• Strong time management and prioritization skills
• Demonstrated ability to maintain confidentiality and ensure HIPAA compliance

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