Clinical Reviewer

This is a fully remote position, open to applicants in Alaska.

📋 Description

• Evaluate the necessity and quality of healthcare services through prospective, concurrent, and retrospective utilization management assessments.

• Utilize clinical review criteria, organizational guidelines, policies, and InterQual screening tools.

• Consult with physician/practitioner consultants when services fail to meet medical necessity standards.

• Work collaboratively with internal teams and escalate cases for further review when necessary.

• Forward cases to management as needed.

• Offer expertise in clinical and utilization review matters.

• Address inquiries from providers, customers, and stakeholders regarding determinations and processes.

• Conduct outreach to providers, case managers, consultants, and community support coordinators to gather additional clinical information.

• Ensure accurate documentation and adherence to regulatory and contractual standards.

• Promote high-quality, appropriate, and cost-effective care while ensuring compliance with clinical criteria, organizational policies, and Alaska-specific contract stipulations.

• Operate remotely in a home-based environment using computers, phones, and virtual communication tools.

• Occasional travel may be necessary for meetings, training, or work-related events.

⛳️ Requirements

• BA/BS in Nursing.

• A combination of education and/or relevant experience may be considered based on contract specifications.

• A minimum of 3 years of direct patient care (clinical) experience.

• A current, active, unrestricted RN license.

• Must fulfill Alaska state and contract-specific requirements.

• Familiarity with InterQual Criteria.

• Strong proficiency in Microsoft Office Suite.

• Knowledge of database systems.

• Exceptional written and verbal communication skills.

• Strong organizational, analytical, and problem-solving skills.

• Ability to juggle multiple priorities in a fully remote, team-oriented environment.

• A reliable and secure internet connection.

• Must maintain licensure eligibility for the assigned state contract.

• Capability to sit for extended durations and communicate effectively.

• A valid driver's license and fulfillment of driving eligibility requirements where applicable.

🏝️ Benefits

• Medical, dental, and vision insurance.

• Paid time off for vacation, illness, and volunteer activities.

• Retirement savings plan with employer contributions.

• Financial assistance for adoption.

• Paid parental leave.

• Annual stipend for workspace enhancements.

• Support for remote work.

• Emphasis on work-life balance.

• Reasonable accommodations for individuals with disabilities.