Remote Clinical Review Nurse

$76,960 - $91,520/Yr

The Csi Companies Inc. Of Florida - Minnetonka, MN

Full-time - Mid Level

Remote - Minnetonka, MN

51-100 employees

About the position

The Remote Clinical Review Nurse is responsible for evaluating and processing specialty injectable documentation to ensure compliance with regulatory and accreditation standards. This role is crucial in maintaining quality patient care through thorough reviews of clinical documentation and effective communication with various stakeholders.

Responsibilities

• Conduct thorough reviews of specialty injectable documentation, interpreting clinical data and applying appropriate criteria and policies to ensure compliance with regulatory and accreditation standards.
• Assess potential quality of care issues based on established clinical policies and benefit determinations, considering all relevant system and additional data.
• Efficiently gather data through multiple system applications and may contact providers, vendors, or internal departments as needed for comprehensive information.
• Review documentation and information to ensure it aligns with clinical policy, regulatory, and accreditation guidelines.
• Apply review requirements to ensure cases are evaluated by clinicians with expertise relevant to the specific clinical issues involved.
• Consistently uphold regulatory and accreditation standards, ensuring timely and compliant review and processing of clinical information.
• Summarize complex clinical information into clear, actionable summaries while maintaining independent judgment.

Requirements

• Active unrestricted RN license
• Bachelor's degree
• Medicare experience
• Experience working in pharmacy prior authorization
• Managed care experience
• Prior authorization experience
• A reliable high-speed internet connection
• Ability to pass a background check and drug test
• Private, quiet, and distraction-free workspace in a room with a closed-door.

Nice-to-haves

• Large corporation experience
• Health plan / managed care / healthcare industry experience

Benefits

• Weekly pay
• Medical, dental, and vision coverage
• Voluntary Life and AD&D coverage
• Paid Training
• Opportunity for advancement upon performance and availability