As the Clinical Reviewer, you will be responsible for the review and processing of all requests for Independent Reviews from External Agencies in accordance with contractual guidelines. Upon receipt of the electronic medical records, communicate with contractors, providers and beneficiary/representatives. Duties include but are not limited to: Performing case reviews utilizing regulatory guidelines criteria and clinical knowledge for medical necessity and quality of care issues; formulate a case summary and the review questions for the Physician Reviewer based upon the External Agency's concern(s), reviewing physician determinations, ensuring all categories of concern have been addressed and preparing written correspondences to contractors, providers and beneficiaries/representatives.
This is a full-time position based in the Jericho, NY office. Ability to work remotely one day per week after introduction period.
QUALIFICATIONS:- The ability to interact with providers, internal/external customers and representatives.
- Excellent communication skills (both verbal and writing) with a professional demeanor
- The ability to work independently, as well as in a team environment.
- Excellent time management/ prioritization skills to meet contractual deadlines while maintaining a high level of quality work to meet customer satisfaction and standards.
- Strong clinical critical thinking skills
- Advanced skills and knowledge of standard EHR applications, office technology and
- Microsoft applications including Word, Excel, and PowerPoint.
- Ability to handle sensitive and confidential information.
EDUCATION & EXPERINCE:- Licensed Registered Nurse, required (open to any RN state license).
- Graduate of a School of Nursing, required.
- Bachelor of Science in Nursing (BSN), required
- A minimum of three (3) years clinical experience in an acute care setting or related experience, required.
- Experience in utilization and quality reviews, required.
- Experience in managed care, quality management and peer review, preferred.
The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. The hourly range for this position is $38.46 - $43.27. Actual salary range and /or hourly rate depends on a variety of factors including experience, education, credentials, location, and budget.
The salary range and/or hourly rate listed does not include other forms of compensation or benefits.
