Clinical Reviewer (RN)

IPRO • Jericho, NY

3d • $38 - $43 • Hybrid

About The Position

The Clinical Reviewer is responsible for reviewing and processing requests for Independent Reviews from External Agencies in accordance with contractual guidelines. After receiving electronic medical records, the reviewer communicates with contractors, providers, and beneficiaries or their representatives. The role includes performing case reviews using regulatory guidelines, criteria, and clinical knowledge to assess medical necessity and quality-of-care issues; preparing case summaries and review questions for the Physician Reviewer based on the External Agency’s concerns; reviewing physician determinations; ensuring all categories of concern have been addressed; and preparing written correspondence to contractors, providers, and beneficiaries or their representatives.

This is a full-time position based in the Jericho, New York office, with the ability to work remotely one day per week after an introduction period.

Requirements

• Licensed Registered Nurse; any state RN license is accepted.
• Graduate of a School of Nursing.
• Bachelor of Science in Nursing (BSN).
• Three years of clinical experience in an acute care setting or related experience.
• Experience in utilization and quality reviews.
• Ability to interact with providers, internal and external customers, and representatives.
• Excellent verbal and written communication skills and a professional demeanor.
• Ability to work independently and in a team environment.
• Excellent time-management and prioritization skills to meet contractual deadlines while maintaining quality and customer satisfaction standards.
• Strong clinical critical-thinking skills.
• Advanced skills and knowledge in standard EHR applications, office technology, and Microsoft Word, Excel, and PowerPoint.
• Ability to handle sensitive and confidential information.

Nice To Haves

• Experience in managed care, quality management, and peer review.

Responsibilities

• Review and process requests for Independent Reviews from External Agencies in accordance with contractual guidelines.
• Communicate with contractors, providers, and beneficiaries or their representatives after receipt of electronic medical records.
• Perform case reviews using regulatory guidelines, criteria, and clinical knowledge to assess medical necessity and quality-of-care issues.
• Formulate case summaries and review questions for the Physician Reviewer based on External Agency concerns.
• Review physician determinations and ensure all categories of concern have been addressed.
• Prepare written correspondence to contractors, providers, and beneficiaries or their representatives.

What This Job Offers

• Job Type: Full-time