Medical, dental, vision, life and supplemental insurance plans effective the first day of the month following date of hire
Short- and long-term disability benefits
401(k) plan with company match and immediate vesting
Free telehealth benefits
Free gym memberships
Employee Incentive Plan
Employee Assistance Program
Rewards and Recognition Programs
Paid Time Off and Paid Sick Leave
Summary Statement
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.
Primary Duties (90% of time)
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).
Secondary Duties (10% of time)
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.
Discuss with CMS leaders and leaders in the provider community.
Participate in special projects as assigned.
Performs other duties as the supervisor may, from time to time, deem necessary.
Required Qualifications
Valid nursing degree
2 years' clinical experience
Excellent written and oral communication skills
Demonstrated experience with evaluating medical and health care delivery issues
Strong computer skills to include Microsoft Office proficiency
Valid unrestricted Registered Nurse (RN) license
The Federal Government and the Centers for Medicare & Medicaid Services (CMS) may require applicants to have lived in the United States for a minimum of three (3) years out of the last five (5) years to be employed with the Company. These years of residence do not have to be consecutive.
Preferred Qualifications
Bachelor of Science in Nursing (BSN)
Insurance industry experience
Certified Coder
Background Investigation
If you are selected for this position, you must undergo a pre‑employment Background Investigation, Drug Screen, and Identity Proofing documentation must be cleared prior to hire. Most positions are subject to additional Identity Proofing, Fingerprinting and additional Background Investigation screening conducted by the Federal Government to be granted Enterprise User Administration (EUA) system logical access after you begin your employment. Your continued employment is contingent upon the outcome of the complete additional screening criteria required for the position which must find that you meet the applicable government customer’s requirements (e.g., suitable for access to CMS information and information systems), as well as any additional investigation which may be required throughout your employment. If you are found not suitable, your employment may be subject to corrective action, up to and including immediate termination of employment.
Equal Opportunity Statement
We are an Equal Opportunity/Protected Veteran/Disabled Employer.
Remote Work Availability
This opportunity is open to remote work in the following approved states: AL, AR, FL, GA, ID, IN, IO, KS, KY, LA, MS, NE, NC, ND, OH, PA, SC, TN, TX, UT, WV, WI, WY. Specific counties and cities within these states may require further approval. In FL and PA, in‑office and hybrid work may also be available.