Clinical Reviewer, Registered Nurse (RN)

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

📋 Description

• Perform prospective (pre-authorization), concurrent (continued stay), and retrospective clinical evaluations for both inpatient and outpatient services, including orthopedic and spine surgeries as well as complex imaging.

• Assess healthcare service requests to establish whether they meet the defined clinical criteria and evaluate the appropriateness of care.

• Utilize established clinical review standards, organizational policies, regulatory mandates, and evidence-based guidelines.

• Analyze clinical documentation and medical records to facilitate accurate and timely decision-making.

• Engage with physician and practitioner consultants when cases fall short of established clinical review criteria.

• Direct cases to qualified clinical professionals for further assessment when necessary.

• Work alongside internal clinical teams to ensure uniform, high-quality review practices.

• Guarantee that clinical reviews are properly documented and conducted in alignment with established protocols and contractual obligations.

• Assist in maintaining compliance with Washington L&I contract stipulations and relevant clinical review standards.

• Provide daily oversight and supervision of non-clinical support activities where applicable.

• Deliver feedback to supervisors on the performance and efficacy of non-clinical support processes.

• Participate in continuous quality improvement initiatives and enhance review operations.

⛳️ Requirements

• Must possess a current, active, unrestricted Registered Nurse (RN) license in the State of Washington.

• A minimum of five (5) years of clinical nursing experience in direct patient care is required.

• Experience in applying clinical judgment to assess patient care, treatment plans, and medical documentation.

• Capability to interpret and apply clinical guidelines, medical necessity criteria, and established healthcare standards.

• Strong clinical assessment and critical-thinking abilities.

• Excellent written and verbal communication skills are essential.

• Proficient in reviewing and interpreting complex clinical documentation.

• Strong organizational skills with a focus on detail and accuracy.

• Ability to work autonomously, prioritize tasks, and meet deadlines.

• Proficient in electronic medical records, clinical documentation systems, and various computer applications.

• Demonstrated professionalism, reliability, and commitment to maintaining confidentiality.

• A Bachelor's degree (BA/BS) is preferred.

• Clinical experience in an Intensive Care Unit (ICU) and/or Emergency Department (ER) setting is preferred.

• Familiarity with medical necessity criteria and evidence-based clinical guidelines is advantageous.

• Experience in collaborating with physician reviewers and multidisciplinary clinical teams is preferred.

• Reliable internet access and a dedicated workspace free from significant distractions are necessary.

• Ability to uphold the confidentiality of protected health information is essential.

• Comfort with using electronic medical records, clinical review applications, and virtual communication tools is required.

🏝️ Benefits

• Opportunity to work remotely within Washington State.

• Comprehensive medical, dental, and vision insurance.

• 401(k) retirement plan with company matching.

• Generous paid time off and paid holidays.

• Annual stipend for home office expenses.

• Opportunities for professional development and continuing education.

• A collaborative, supportive, and mission-driven work environment.

• Chance to make a meaningful impact on healthcare quality and patient outcomes.