RN Performance Monitor Specialist, Clinic

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

📋 Description

• Perform assessments of clinical files by examining assigned documentation to ensure compliance with clinical standards.

• Contribute to the creation and continuous evaluation of tools for clinical review.

• Review program descriptions, policies, procedures, action steps, training materials, and State Contracts as necessary.

• Assess the coherence of review tool components, departmental processes, staff training, and contractual or departmental criteria.

• Apply clinical expertise and experience to appraise documentation related to member health assessments, clinical requirements, and interventions.

• Engage in meetings to discuss findings from reviews, identify opportunities for enhancement, and provide recommendations.

• Raise any concerns discovered during clinical file evaluations.

• Assist in preparing for audits by State, CMS, and NCQA by gathering and/or reviewing pertinent clinical information.

• Achieve set productivity and interrater reliability benchmarks for file reviews.

• Adhere to departmental guidelines, processes, policies, and standards.

• Execute additional responsibilities as assigned.

⛳️ Requirements

• A Bachelor's Degree in Nursing, Clinical Social Work/Counseling is required, or an Associate's degree with an RN and at least 3 years of clinical experience.

• A minimum of 3 years in a clinical setting (either inpatient or outpatient) is required.

• At least 1 year of experience in Managed Care (UM, BH, CM) is preferred.

• Understanding of Medicare and Medicaid programs is preferable.

• A license in one of the following is mandatory: Licensed Registered Nurse (RN), Licensed Clinical Social Worker (LCSW), Licensed Mental Health Counselor (LMHC), or Licensed Marital and Family Therapist (LMFT).

• Certification as a Case Manager (CCM) is preferred.

• RN with experience in Utilization Management is desirable.

• Experience with Prior Authorization is highly preferred.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K and stock purchase opportunities.

• Tuition reimbursement available.

• Paid time off in addition to holidays.

• Flexible work options including remote, hybrid, field, or office schedules.

• Additional incentive programs may be included in total compensation.

• We are an equal opportunity employer dedicated to fostering diversity.