Compact RN Clinical Review Nurse

Job Summary

Working remotely on a full-time basis, the Compact RN Clinical Review Nurse will draft correspondence letters based on clinical review outcomes, ensuring compliance with NCQA standards while collaborating with senior management to identify improvement opportunities.

Key responsibilities

• Perform clinical reviews and create/edit denial letters in line with NCQA standards
• Investigate denials by reviewing clinical documentation and provide supplemental information to resolve claims
• Coordinate with interdepartmental teams to identify training needs and provide feedback for process improvements

Required qualifications

• Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing
• 2 - 4 years of related experience in clinical review or utilization management
• Compact RN License required
• Knowledge of Medicare and Medicaid regulations preferred
• Knowledge of utilization management processes preferred