Job Summary
The purpose of this position is to utilize clinical expertise to review medical records against established criteria in accordance with contract requirements.
Location: Remote (U.S.-based)
Licensure Requirement: Must hold an active clinical license in the State of Indiana or a Compact State license
Work Schedule:
- Up to 25 hours per week
- Weekend and/or holiday availability required based on business needs
Training Requirement:
- Must be fully available to attend 100% of training
- Schedule: Monday–Friday, 9:00 AM – 6:00 PM EST
- Duration: Minimum of 3 weeks
Key Responsibilities
- Ensure accuracy and timeliness of all review cases in accordance with contract requirements
- Manage daily workload and queues; adjust workflow as needed to meet departmental demands
- Collaborate with Supervisor on quality monitoring and improvement activities
- Maintain current knowledge of clinical practices and review processes
- Serve as a liaison for providers regarding customer service issues and resolution
- Perform various review types as assigned based on workload
- Build and maintain professional relationships with internal and external stakeholders
- Attend required trainings and team meetings
- Cross-train to support business and client needs
- Comply with all corporate policies, including HIPAA Privacy and Security regulations
Note: Responsibilities may evolve based on business needs.
Required Qualifications
- Active, unrestricted LPN/LVN or RN license in Indiana or Compact State
- Associate’s degree (Bachelor’s preferred) or diploma from an accredited nursing program
- 2+ years of Utilization Review/Management (UR/UM) and/or Prior Authorization experience
- 2+ years of medical necessity review experience
- 1+ year of InterQual and/or Milliman Care Guidelines (MCG) experience
- Strong knowledge of medical records, terminology, and disease processes
- Excellent clinical assessment and critical thinking skills
- Strong written and verbal communication skills
- Ability to navigate multiple systems efficiently
- Strong organizational skills and flexibility
Preferred Qualifications
- 3+ years of clinical experience (acute care, behavioral health, and/or med-surgical)
- Knowledge of NCQA and URAC standards
- Experience working in a team-based environment
- Proficiency in Microsoft Office
- Strong time management and prioritization skills
- Demonstrated ability to maintain confidentiality and ensure HIPAA compliance
Weekend and holiday flexibility is required
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