Clinical Review Nurse I

This is a fully remote position, open to applicants in Kentucky, +2 more states.

📋 Description

• Evaluate and determine if pre-claim reviews and/or claims align with the member’s benefits.

• Analyze the necessity and appropriateness of items provided in legitimate claims.

• Utilize medical policy and other relevant materials to inform decisions.

• Effectively communicate health information in accordance with medical policy and established criteria.

• Fulfill mandatory in-person training and onboarding requirements.

• Adhere to Government Business Division policies, procedures, guidelines, training, monitoring, and sensitive-data handling protocols as necessary.

⛳️ Requirements

• An associate degree in nursing is required, or a comparable combination of education and experience.

• A minimum of 1 year of clinical experience is necessary.

• A current unrestricted RN license is mandatory.

• The ability to understand medical policy and criteria, and to articulate health information clearly, is highly preferred.

• Candidates must live within a reasonable commuting distance of the job location unless a special accommodation is made.

• Individuals in sensitive Government Business Division roles may be subject to rigorous and frequent background checks and/or government clearances.

• Candidates in sensitive Government Business Division roles must comply with segregation-of-duties principles, receive role-specific training, monitor daily job functions, and follow sensitive-data handling instructions.

• Candidates in specific patient/member-facing positions are required to be vaccinated against COVID-19 and Influenza, unless a valid exemption is provided.

🏝️ Benefits

• Comprehensive benefits package.

• Incentive and recognition programs.

• Equity stock purchase options.

• 401(k) contributions.

• Merit-based salary increases.

• Paid holidays.

• Paid Time Off.

• Incentive bonus programs.

• Medical benefits.

• Dental benefits.

• Vision benefits.

• Short-term disability coverage.

• Long-term disability coverage.

• 401(k) plan with company match.

• Stock purchase plan.

• Life insurance.

• Wellness programs.

• Financial education resources.

• Mandatory in-person training sessions.

• Flexible and autonomous virtual work arrangement.