Senior Clinical Quality Nurse Reviewer - Prior Auth/UM

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

📋 Description

• Conduct quality assurance audits in accordance with established clinical guidelines and policies.

• Review and analyze production and appeal documentation to ensure accuracy, completeness, regulatory compliance, achievement of production goals, and adherence to quality standards.

• Record quality review findings for trending analysis and reporting purposes.

• Detect quality trends and collaborate with leadership to create remediation strategies, educational resources, and training programs.

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

• Keep updated knowledge of clinical criteria guidelines.

• Participate in training sessions and attend scheduled meetings.

• Engage in cross-training to conduct reviews across various claim types.

• Act as a subject matter expert and play a role in the business proposal process.

• Assist with projects, data analysis, reporting, and providing feedback.

• Conduct medical reviews, chart audits, and quality improvement initiatives.

• Evaluate medical information and utilize clinical review guidelines and judgment to make clinical decisions.

• Take part in inter-rater reliability assessments and audits related to Place of Service, Level of Care, Readmissions, Utilization Management, and specialty reviews.

⛳️ Requirements

• Must possess an active, unrestricted RN license in the United States and in the state of primary residence.

• An active, unrestricted multistate compact RN license as outlined by the Nurse Licensure Compact (NLC) is necessary.

• An associate degree is required; a bachelor's degree is preferred.

• Minimum of 5 years of clinical experience in an acute care environment.

• Preferred 5+ years of experience in medical record review/auditing, utilization management, or appeals/hearing processes.

• At least 3 years of experience in applying national evidence-based guidelines (InterQual and/or MCG).

• Expert-level proficiency in applying MCG and/or InterQual criteria.

• Certification in MCG or InterQual is preferred.

• Exceptional written communication abilities, including the capacity to create clear, concise, accurate, fact-based rationales.

• Proficient in multitasking within a fast-paced production setting, adapting to changing priorities, and transitioning between client interactions.

• Must be able to complete required CEUs to sustain RN licensure.

🏝️ Benefits

• Flexible working hours.

• Emphasis on work-life balance.

• Opportunities for continuous learning and career advancement.

• Flexible vacation policy.

• Employer match for 401(k).

• Comprehensive health benefits package.

• Educational assistance provided.

• Access to leadership and technical development academies.