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Georgia Employer NURSE REVIEWER in Atlanta, Georgia

DescriptionWe are seeking a talented individual for a Nurse Reviewer who will be responsible for performing clinical reviews to determine if the medical record documentation supports the need for the service based on clinical criteria, coverage policies, and utilization and practice guidelines as defined by review methodologies specific to the contract for which services are being provided. This involves accessing proprietary systems to audit medical records, accurately documenting findings and providing policy/regulatory support for determination.Responsibilities:Reviews and interprets medical records and compares against criteria to determine appropriateness and reasonableness of care; apply critical thinking and decision-making skills to determine if the medical record documentation supports the need for service while maintaining production goals and quality standards.Document decisions and rationale to justify review findings or no findings.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 and completed within contractual deadline.Performs prior authorization, precertification, and retrospective reviews and prepares decision letters as needed in support of the utilization review contractAssists management with training new Nurse Reviewers to include daily monitoring, mentoring, feedback and education.Maintains current knowledge of clinical criteria guidelines and successfully completes required CEUs to maintain RN licenseResponsible for attending training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations.Actively cross-trains to perform reviews of multiple claim types to provide a flexible workforce to meet client needs.Recommends, tests and implements process improvements, new audit concepts, and technology improvements that will enhance production, quality, and client satisfactionRequirements:Education (required)Associates or Bachelor's degree in Nursing (active / unrestricted license)Certification (preferred)Case Management certification - preferredExperience5+ years' clinical experience in an inpatient setting2 + years' utilization review experience or claims auditing experienceCase Management experience highly preferredHigh level of proficiency in Milliman and Interqual guidelinesAbility to analyze and evaluate medical information and to apply clinical review guidelines or judgement to make clinical determinations.Demonstrated experience in medical review, chart audits, and quality improvement processes.Demonstrated ability to write clear, accurate, concise rationales in support of findings.Working knowledge of HIPAA Privacy and Security Rules.Ability to multi-task in a fast-paced working environment.Ability to work in a production environmentAbility to build relationships both internally and externally.Demonstrated proficiency in computer skills, and typing, i.e., Microsoft Windows, Outlook, Excel, Word, PowerPoint, Internet browsers, etc.Demonstrated proficiency in virtual meeting tools i.e., Microsoft Teams, Zoom, etc.Work Environment:This is an at home-based position and you must have a work location within the continental USInterviewing & training will be done remotely.This position requires that you provide a high speed internet connection and a work environment free from distractionsThis role is aligned to certain productivity and quality requirements#LI-JB1#LI-RemoteThe 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... For full info follow application link.Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

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