RN Reviewer

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

📋 Description

• Conduct prospective reviews (prior authorization), as well as admission, concurrent, and retrospective evaluations.

• Evaluate the medical appropriateness and necessity of clinical requests submitted by providers.

• Assess inpatient admissions, outpatient services, and procedures, including requests from out-of-network providers.

• Review various lines of business including Commercial, Medicare, and Medicaid.

• Collaborate with Medical Directors and providers to make informed clinical decisions.

• Accurately document reviews while meeting production and quality standards.

• Utilize MCG, Cohere, and coverage guidelines to ensure compliance and consistency.

• Work in partnership with Operations, Product, Quality, and Health Plans teams to enhance processes and outcomes.

• Identify opportunities for care management and quality improvement initiatives.

• Support accreditation, regulatory, and quality programs.

⛳️ Requirements

• Must hold an active, unencumbered RN license in your state of residence.

• Minimum of 3 years of clinical experience required.

• Experience in Utilization Management is essential.

• Background in acute or post-acute care settings is preferred.

• Strong understanding of utilization and case management programs.

• Familiarity with NCQA/CMS standards is necessary.

• Proficient in MCG; experience with CareWebQI is an advantage.

• Comfortable with Mac and Google Workspace applications.

• Excellent communication and collaboration skills, particularly in remote team settings.

• Customer-oriented approach with the ability to maintain composure under pressure.

• Adaptability to thrive in a fast-paced startup environment.

• Highly organized, detail-focused, and capable of managing multiple priorities.

• Bachelor's degree in Nursing, Business, or a related field is required.

• Internet speeds exceeding 50 megabytes/second are necessary for Zoom and video streaming.

• Preferred qualifications include HEDIS abstraction, Legal RN, or Utilization Review experience.

🏝️ Benefits

• Fully remote position with approximately 5% travel required.

• Comprehensive medical, dental, vision, life, and disability insurance plans.

• Access to an Employee Assistance Program.

• 401K retirement plan with company matching contributions.

• Flexible spending account options.

• Health savings account available.

• Up to 184 hours (23 days) of paid time off annually, plus company holidays.

• Up to 14 weeks of paid parental leave offered.

• Pet insurance included.

• Bonus opportunities as part of the total benefits package.