Job description
Job Title: Registered Nurse Clinical / Medicare / Utilization Review
Utilizes clinical expertise for the review of Medicare and Medicaid medical records against appropriate criteria in conjunction with contract requirements, critical thinking and decision-making skills to determine medical appropriateness, while maintaining production goals and QA standards. Ensures day-to-day processes are conducted in accordance with NCQA, URAC and other regulatory standards.
Active unrestricted RN clinical license, eligible for Ohio reciprocity licensing. Graduation from an accredited Diploma, Associates Degree or Bachelor’s Degree Program
Experience**
- Knowledge of Medicare/Medicaid criteria strongly preferred.
- Knowledge of the organization of medical records, medical terminology, and disease process required.
- Strong clinical assessment and critical thinking skills required.
- Excellent verbal and written communication skills required.
- Must be proficient in Microsoft Office and internet/web navigation
- Minimum three (3) years of clinical experience in an acute or med-surgical environment required.
- Minimum of one (1) year UR and/or Prior Authorization or related experience.
- Spanish as second language is desirable.
- Medical Coding certification or experience is desirable.
Job Type: Full-time. This is a work at home position.
COVID-19 considerations:
Must show proof of COVID vaccination.
Job Type: Full-time
Pay: $35.00 - $40.00 per hour
Benefits:
- 401(k)
- 401(k) matching
- Employee assistance program
- Flexible schedule
Education:
Experience:
- Utilization review: 3 years (Required)
License/Certification:
- RN (without restrictions) (Required)
Work Location: Remote
