Registered Nurse/Medicaid Clinical Reviewer
About The Position
We are seeking an experienced Registered Nurse to join our team as a Medicaid Clinical Reviewer. This fully remote position involves conducting clinical reviews for Medicaid cases, ensuring compliance with state regulations, and contributing to quality improvement initiatives for a respected non-profit organization. Work Schedule: Full-time, Monday to Friday (9:00 AM - 5:30 PM), Fully Remote. Professional Growth: Gain valuable experience in a collaborative, innovative, and supportive environment. Impactful Work: Contribute to a mission-driven organization dedicated to improving patient outcomes through quality Medicaid program oversight.
Requirements
- Graduate of an accredited nursing program
- Active RN State license and active NY State License
- 1-3 years of experience in Case Review, Utilization, Billing, and coding review
- InterQual and Milliman experience required
- At least 2 years of Med/Surg experience
- Proficiency with Microsoft Outlook, Word, and spreadsheets
- Comfortable working extensively on computer systems
- Strong analytical skills
- Attention to detail
- Ability to work independently in a remote environment
Responsibilities
- Conduct utilization reviews up to and including the appeal level.
- Complete chart screening, electronic worksheets, and enter required information.
- Make level one denial decisions when necessary.
- Conduct quality and clinical study data collection reviews.
- Act as a resource for administrative staff in training, problem-solving, and clarifying procedures.
- Participate in collaborative training specific to clinical study objectives.
- Use InterQual criteria to review medical records of inpatient high cost hospital stays for admission and acute level of care.
- Review and validate itemized bills.
- Write up responses to send to the hospital.
- Complete the full spectrum of activities related to Medicaid Utilization or Quality reviews as assigned.
- Conduct final level insurance appeals and review medical records.
Benefits
- 1 Week Paid Vacation based on accruals
- 6 Major Paid Holidays per year
- 5 Sick Days (40 Hours) subject to the provisions of NYS Paid Sick Leave Act
- License Reimbursement after 1 year of employment
- Health insurance is subject to plan eligibility requirements
- 401k Matching eligibility after 1 year of employment
- Benefits from Paychex, such as Payactiv
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
