Job Title: Clinical Review Nurse
Hourly Rate: $5.50-$6.00
Start Date: ASAP
Full time
Position Overview
The Clinical Review Nurse plays a vital role in ensuring the accuracy, quality, and compliance of medical documentation and healthcare services. This position involves conducting clinical reviews of patient records, medical necessity determinations, and treatment plans to support utilization management, quality assurance, and claims adjudication. Working collaboratively with physicians, case managers, and insurance providers, the Clinical Review Nurse ensures that care delivered aligns with evidence-based guidelines and payer requirements. The ideal candidate brings strong clinical judgment, attention to detail, and a solid understanding of medical policies, coding, and regulatory standards.
Job Responsibilities:
- Identifies and determines the viability of authorizations and secures documentation to support
determinations.
- Utilizes Review Criteria to pre-screen authorization requests for medical necessity and appropriateness.
- Completes re-visits and new patient start of care as requested.
- Performs comprehensive assessments of the patient and reviews results of laboratory tests and other diagnostic procedures.
- Compares assessment data to baseline assessment to monitor the patient’s progress.
- Initiates patient education and participates in the development of patient goals and discharge plans
- Participates in the utilization review of medical records as assigned.
- Completes and submits OASIS assessments, reassessments, transfers, resumptions of care, discharges, and significant change in condition.
Job Qualifications:
- Must have a Bachelor of Science in Nursing, BSN
- Current RN (Registered Nurse) license required
- Minimum of two (2) years related experience required.
- Excellent and professional communication skills, in both verbal and written format, required.
- Nursing experience in a Home Health setting preferred.
- Working knowledge of Medicare preferred.
- Strong understanding of continuum of care preferred. Must demonstrate the ability to work
- independently, as well as cohesively as necessary.
- Must be detail oriented and work well under pressure.
- Excellent and professional communication skills, in both verbal and written format, required.
Hardware and Software Requirements:
Hardware:
- AMD Ryzen 3 3200G APU or Intel Core i5 (at least 7th gen) Intel CPU
- 16GB DDR4 RAM
- 120 – 480gb SSD
- Jabra Biz 1100 / Logitech H390 or similar Noise-canceling Headset
- 1 – 2 Monitors (at least 21in)
- 1080p HD Webcam
- Internet Speed: 50mbps (Fiber/DSL) LTE not accepted
Software:
- Genuine Windows 10 Licensed Computer
- Microsoft Office Suite