Senior Clinical Reviewer (RN)

* Position is eligible for Remote / Work from Home opportunity * Hiring Manager: Marcy Craythorn & Becky Borgen Department: Part B Medical Review Talent Partner: Lacy Ecker Telecommuting Eligible: Yes Job Grade: E12 Notice of Collection & Privacy Policy for Applicants Residing in California: California Applicant Privacy Policy | Noridian (noridiansolutions.
com) Job Title Senior Clinical Reviewer (RN) Job Summary The Senior Clinical Reviewer (RN) provides project leadership and people guidance.
The role also serves as a resource and liaison to staff, leadership, teams and external entities using effective communication, training, and quality process development.
Essential Functions Key Duties/Responsibilities/Accountabilities Reviews, researches, and analyzes medical records and other documentation to determine compliance with regulations, guidelines, and standards of care.
Applies accurate, independent coverage and payment decisions using consistent evaluation standards.
Communicates decisions and provides associated education to stakeholders using various methods.
Determines recommendations for actions based on analysis of review results.
Prioritizes workload depending on business need and direction.
Identifies and communicates potential fraud, waste, and abuse using established work instructions.
Collaborates and communicates with peers and leaders.
Participates in team quality and calibration review processes.
Serves as a mentor to peers.
May prepare documents for, and participate in, legal hearings.
Mentors and trains other providing support, guidance, motivation, assistance, quality assessment and leadership.
Creates coordinates, monitors, tracks, and updates training resources and training sessions and performs training.
Leads, participates, and represents team in workgroups, meetings and internal and external communications.
Identifies, analyzes, researches, and assists in problem resolution and continuous improvement.
Leads, participates, supports, and reports on special projects and assignments.
Develops and contributes to narratives and data analysis for reporting.
Researches, analyzes, and maintains a comprehensive understanding of clinical information, regulations, guidelines, standards of care, etc.
for training, application, and resource maintenance.
Collaborates with Medical Directors and other subject matter experts in determining, communicating, maintaining, and applying consistent review guidelines.
Collaborates and communicates with internal and external stakeholders as needed.
May perform clinical review as needed.
Non-Essential Duties and Functions Assists with special projects as assigned.
Minimum Qualifications Current, active, unrestricted RN license in state of practice 2 years' clinical experience 2 year Microsoft Office experience 1 year experience leading projects, initiatives, or processes 1 year experience mentoring and training staff 1 year experience educating external customers Strong verbal and written communication skills Strong critical thinking and problem resolution experience Strong attention to detail Strong computer experience Preferred Qualifications Above requirements and the following: Bachelor's degree in Nursing (BSN, BAN, etc.
) 3 years' experience evaluating medical records applying clinical expertise to determine compliance with applicable guidelines and standards of care 3 years' experience utilization review or case management 3 years' experience educating external customers 3 years' experience leading projects, initiatives, or processes 3 years' experience mentoring and training staff 3 years' experience assessing quality 2 years' experience contributing to reporting, including data analytics and interpretation Strong prioritization, problem solving, and organizational skills Strong attention to detail Knowledge of coding Microsoft proficiency Strong business writing experience Environment and Cognitive/Physical Demands Office Environment Ability to read, hear, speak, keyboard, reason, communicate effectively and problem solve Requires prolonged sitting and telephone use Requires the use of office equipment such as computer terminals, telephones, copiers and printers Infrequent lifting to 15 pounds Infrequent stooping Segregation of Duties Every employee is responsible to perform their duties and responsibilities in accordance with Noridian values, policies and procedures, including but not limited to: Segregation of Duties Principles, HIPAA, Security and Privacy, CMS requirements, the Noridian Compliance Program and any other applicable laws, rules and regulations.
Statement of Other Duties This document describes the essential functions, requirements, and responsibilities of this job, and is not intended to be a complete list of all tasks and functions.
Employees may be requested to perform job related tasks other than those specifically listed in this description and may be required to perform any task requested by the supervisor or management.
Total Rewards Package: Health, Dental and Vision Insurance, Voluntary Insurance Plans, Health Savings and Flexible Spending Accounts, 401k and Company Match, Company-paid Life Insurance, Education Assistance Program, Paid Sick Leave, Paid Holidays, Increasing PTO Accrual Plan, Medical/Parental/Disability Leave, Workers Compensation, Retiree Benefits, Severance Package, Employee Assistance Program, Financial and Health Wellness Benefits, Casual Dress, Open Office Setting, and Online Learning System.
CMS Access Compliance and Regulation Contingency Statement Some positions require compliance with (i) federal and agency specific regulations and related clauses included in Noridian's prime contracts with the Government, (ii) background checks, and (iii) eligibility for a government-issued identification card.
Equal Employment Opportunity Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities as well as Sexual Orientation or Gender Identity.
Below is the salary range for potential new hires.
Salary Range: $59,938 – $98,583 Other Compensation: Incentive Plan Lifestyle Benefit: $50/month This job will be closed 02/09/2024 at 8:00AM CST.
No further applications will be considered.
Licenses & Certifications Required Registered Nurse Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant.
However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information.
41 CFR 60-1.
35(c)