Clinical - Clinical Review Nurse - Concurrent Review - J00933

Location : Remote - TX nursing license or compact nursing license.

This is a Tuesday through Saturday position. 12 pm - 9 pm CST. There may be at times, OT expectations based on business needs. This team does work holidays, which are rotated amongst the team members .

RN is required, either a TX nursing license or compact nursing license.

Duration : 12 months contract

Job Description : will be working with the Tx Correspondence Team, working with client's Health Plan. Tx Correspondence Team is part Shared Services, which oversees many markets and states. The purpose of the team is to ensure that the members and requesting providers receive the written documentation of a denied service. Working within a highly engaged team remotely, with ongoing support to produce denial correspondence based off the advisor review that is in easy-to-understand language to the member and adheres to the NCQA and state standards. There may be at times, OT expectations based on business needs. This team does work holidays, which are rotated amongst the team members.

Candidate Requirements

Education / Certification

Required : Requires graduated from an accredited school of nursing or Bachelor s degree in nursing

Preferred : 2-4 years of related experience

Licensure

Required : RN is required, either a TX nursing license or compact nursing license

Preferred : Compact

• Years of experience required
• Best vs. average
• Performance indicators

Must haves : Minimum 1 year nursing experience.

Nice to haves : Knowledge of Medicare and Medicaid regulations; Knowledge of utilization management

Disqualifiers :

Performance indicators : Metric driven in production and quality

Ability to critically think

Ability to effectively use Microsoft OneNote and Word

Ability to work remotely, i.e. meet production deadlines; quality metrics