Nurse Reviewer – IMR

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

📋 Description

• Conduct clinical reviews to assess if medical record documentation justifies the need for services.

• Implement clinical criteria, coverage policies, utilization guidelines, and practice standards relevant to the specific contract.

• Compile appeal packages for physician assessment for independent medical review (IMR).

• Verify the clinical appropriateness of IMR determination letters.

• Assess and prioritize the necessity of expedited IMR appeal requests following federal guidelines and state regulations.

• Execute level-of-care and utilization reviews by evaluating medical records against established criteria.

• Utilize critical thinking and decision-making abilities while achieving production goals and maintaining quality standards.

• Support management in training new reviewers through monitoring, mentoring, providing feedback, and education.

• Keep abreast of current clinical criteria and/or coding guidelines.

• Participate in training sessions and scheduled meetings.

• Acquire cross-training to conduct reviews of various claim types.

• Engage in frequent collaboration with team members and other departments within the company.

⛳️ Requirements

• A valid, unrestricted RN license from the United States in the primary home residency, or an active compact multistate unrestricted RN license under the Nurse Licensure Compact (NLC) is required.

• A minimum of 5 years of clinical experience in an inpatient hospital environment is required.

• At least 3 years of experience in utilization review or claims auditing preferred.

• Proficiency in using InterQual criteria is required.

• Capacity to manage multiple tasks in a fast-paced production setting.

• Work location must be within the continental United States.

• A high-speed internet connection is necessary.

• A work environment that is free from distractions is essential.

• Availability to work during standard business hours.

• Willingness to work extended hours or be on call every other weekend as needed by the business.

• Travel may be required for at least 10% of the time based on business needs.

• Ability to complete necessary CEUs to maintain RN licensure.

🏝️ Benefits

• Flexible working hours.

• Emphasis on work-life balance.

• Opportunities for continuous learning and career advancement.

• Flexible vacation policy.

• 401(k) employer matching.

• Comprehensive health benefits.

• Educational assistance available.

• Leadership and technical development academies offered.

• High-speed internet and a distraction-free home work environment are required (not a benefit).

• Potential for travel reimbursement not explicitly stated.