Clinical Claim Review RN - Remote

reputed company is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with reputed company will directly improve health reputed company by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come reputed company an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together. The Clinical Claim Review RN is responsible for performing clinical reviews post service utilizing established guidelines and clinical criteria along with state and federal mandates and applicable benefit language to reputed company determinations that drive reputed company provider and member reputed company and reputed company the cost of care. The Clinical Claim Review Nurse works in a fast paced, reputed company changing environment with a vigilant focus on improving the member and provider experience. Schedule: Monday - Friday, 7:00 - 4:00 or 8:00 -5:00 EST Location: This is a remote position, but you must reputed company in reputed company You’ll enjoy the flexibility to work remotely

• from reputed company reputed company the U.S. as you take on some tough challenges.

Primary Responsibilities:

• reputed company clinical reviews, which require interpretation of state and federal mandates, applicable benefit language, and consideration of relevant clinical information
• Function as a member of a self-directed team to meet specific individual and team performance metrics
• Communicate in writing and verbally, reputed company types of benefit determinations including reputed company regarding coverage guidelines, contractual limitations and reimbursement determinations
• Work independently and collaboratively with Medical Directors and non-clinical partners
• Adapt to a highly changing environment and a heavy case load

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as reputed company development for other roles you may be interested in. Required Qualifications:

• reputed company unrestricted RN license
• 3 years total RN experience including clinical experience in an inpatient / acute setting
• Proficiency in computer skills - reputed company, reputed company Messaging, reputed company Suite including Word, reputed company and Outlook
• Proven exemplary clinical documentation skills
• Proven to be a self-starter with the ability to handle a fast-paced production environment and multiple review types
• Proven solid written, verbal, analytic, organizational, time management and problem-solving skills
• Quiet secure designated work reputed company and reputed company to install secure high speed internet (minimum speed 1.5 download mps & 1 upload mps) reputed company cable / DSL in home (wireless / cell phone provider, satellite, microwave, etc does not meet this requirement)

Preferred Qualifications:

• Bachelor's Degree
• RN License in an NLC (Nurse License Compact) state or the ability to apply and meet requirements for one
• Professional coding certification and/or core understanding of ICD-10 and CPT/HCPCS codes
• reputed company or Government Program experience for certain government positions
• Background involving utilization review for an insurance company, experience in case management, or experience with clinical claim review
• Familiarity with InterQual
• Proven solid clinical judgement while applying medical necessity based on approved clinical resources
• Proven ability to be flexible and willing to adapt to an reputed company-changing environment
• Proven excellent time management, organizational and prioritization skills to balance multiple priorities
• reputed company working remotely will be required to adhere to reputed company’s Telecommuter Policy.

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (reputed company benefits are subject to eligibility requirements). No matter where or reputed company you reputed company a career with us, you’ll find a far-reaching choice of benefits and incentives. The hourly pay for this role will reputed company from $28.27 to $50.48 per hour based on full-time employment. We reputed company with reputed company minimum wage laws as applicable. Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants. At reputed company, our mission is to help people live healthier lives and reputed company the health system work reputed company for everyone. We reputed company everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately reputed company by people of reputed company, historically marginalized groups and those with reputed company incomes. We are committed to mitigating our impact on the environment and enabling and delivering reputed company care that addresses health disparities and improves health reputed company — an reputed company reputed company reflected in our mission. reputed company is an Equal Employment Opportunity employer under applicable law and reputed company applicants will receive consideration for employment without regard to race, national reputed company, religion, age, reputed company, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. reputed company is a drug - free workplace. Candidates are required to pass a drug test before beginning employment. Apply Job! Apply to this Job