Clinical Reviewer

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

📋 Description

• Assess authorization requests and the accompanying medical documentation for medical necessity and suitability.

• Implement workers’ compensation treatment guidelines, clinical criteria, organizational policies, InterQual criteria, screening tools, and contract stipulations specific to Alaska.

• Approve suitable cases or escalate cases needing further evaluation to Medical Affairs, physician reviewers, management, or consultants.

• Perform prospective, concurrent, and retrospective utilization management reviews.

• Investigate relevant treatment guidelines and record decisions along with their supporting rationale.

• Handle pended cases and acquire additional information from providers or the claims system.

• Engage with clinics and address inquiries from providers, customers, and stakeholders.

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

• Conduct outreach to providers, case managers, consultants, and community support coordinators.

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

• Collaborate with physician advisors, providers, and internal teams to ensure accurate, timely, and thoroughly documented review outcomes.

• Offer expertise in clinical and utilization review matters.

⛳️ Requirements

• Availability for a minimum of two four-hour shifts each week.

• At least 3 years of direct patient care (clinical) experience.

• Current, active, and unrestricted RN license and/or LCSW, LMHC, LCP.

• Experience with InterQual Criteria.

• Strong proficiency in Microsoft Office Suite.

• Familiarity with database systems.

• Excellent verbal and written communication abilities.

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

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

• Reliable and secure internet connection.

• Must maintain licensure eligibility for the assigned state contract.

• Must be capable of sitting for extended periods and communicating effectively.

• Valid driver's license and compliance with driving eligibility requirements where business vehicle operation is necessary.

🏝️ Benefits

• Fully remote work opportunity.

• Annual stipend for workspace enhancement.

• Support for work-life balance.

• Occasional travel required for meetings, training, or other work-related events.

• Reasonable accommodations available for individuals with disabilities.