Nurse Clinical Reviewer (RN or LPN)

Nurse Clinical Reviewer (RN or LPN)

• Are you an experienced Nurse (LPN/RN) looking for a new opportunity?
• Do you have three or more years’ experience as a Nurse?
• Are you seeking the flexibility to work from home?
• Do you value care management and quality improvement?
• Are you motivated, energetic, and excited to become part of a team dedicated to quality?

If so, we should talk!

Who we need:

Our Nurse Clinical Reviewer will use clinical expertise for the review of medical records against appropriate criteria in conjunction with contract requirements, critical thinking, and decision-making skills to determine medical appropriateness, while maintaining production goals and QA standards. Ensures day-to-day processes are conducted in accordance with NCQA, URAC and other regulatory standards.

Who are we?

Axon Advisors has been brokering subject matter experts for over sixteen years. One of our clients, Acentra, has requested our assistance in identifying relevant subject matter experts (nurse clinical reviewers) for a 4-6 year contract. Acentra is a rapidly growing national quality improvement and care management organization. They work to ensure that over 20 million people receive the right care, at the right time, in the right setting. With Acentra, you can do meaningful work that makes a real difference for the lives of individuals across the country. They are an organization that cares deeply about their contractors and will provide the training and support for you to do the best work of your career.

What you’ll do:

This role ensures day-to-day processes are conducted in accordance with NCQA, URAC and other regulatory standards. Computer equipment will be provided. You will need to provide a reliable internet connection to perform this work. Daily tasks and responsibilities include:

• Reviews and interprets patient records and compares against criteria to determine medical necessity and appropriateness of care; determines if the medical record documentation supports the need for services.
• Determines approval or initiates a referral to the physician consultant and processes physician consultant decisions ensuring reason for the denial is described in sufficient detail on correspondence.
• Foster positive and professional relationships and act as liaison with internal and external customers to ensure effective working relationships and team building in order to facilitate the review process.
• Responsible for attending training and scheduled meetings and for maintenance and use of current/updated information for review.
• Maintains medical records confidentiality at all times through proper use of computer passwords, maintenance of secured files, adherence to HIPAA polices.
• Utilizes proper telephone etiquette and judicious use of other verbal and written communications, following standard policies, procedures, and guidelines. Training is provided.
• Other duties as assigned

Profile we are seeking:

Required Qualifications

• Active unrestricted LPN or RN license in the State of Indiana or a compact state license
• Strong clinical assessment and critical thinking skills required.
• A commitment to care quality improvement.

Knowledge, Skills, Abilities

• Knowledge of Interqual or ASAM guidelines
• Knowledge of InterQual or ASAM criteria strongly preferred.
• Knowledge of current NCQA/URAC standards strongly preferred
• Ability to prioritize, assign, and follow up on work
• Ability to problem solve
• Ability to provide technical consultation and policy interpretation
• Excellent customer service
• Excellent written and verbal communication skills
• Microsoft Office basic skills

Experience

• Minimum of one year UR and/or Prior Authorization or related experience.
• Minimum 3 years direct experience in a clinical setting or other applicable State and/or Compact State clinical experience or license per contract requirements.

Work Schedule

• Full-time or part-time.
• Remote location (not onsite).
• Optional hours:
  • FT: Wed-Sat, 10 hrs/day
  • PT: Wed-Sat, 5 hrs/day
  • PT: Sat-Sun, 10 hrs/day

How to Apply!

We know your time is valuable and we thank you in advance for applying for this position. Due to the volume of responses, we may not be able to reply to every application. However, we sincerely appreciate your interest in this position.

Mental and Physical Requirements

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations will be made as required by law in an attempt to enable an individual with a disability to perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to sit for prolonged periods of time; key and/or control objects; work in front of a computer monitor for extended periods; interact extensively with internal and external customers; occasionally lift and/or move objects weighing up to 10 pounds; and occasionally travel within the state.

EOE AA M/F/Vet/Disability

Axon Advisors is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.