clinical nurse reviewer

Liberty Healthcare Corporation

<div>Registered Nurses are encouraged to consider a full-time Clinical Reviewer position with Liberty Healthcare.

As a Clinical Reviewer, you will be an active contributor with a large-scale program which endeavors to enrich the lives of older adults and people who are living with developmental disabilities.

Your role will focus on the review and analysis of health information of recipients of Medicaid HCBS waiver services, and your day-to-day responsibilities will include:
<ul>
<li>Reviewing medical records and personal health information</li>
</ul><ul><li>Conducting root cause analyses of critical incidents and deaths</li>
</ul><ul><li>Forming objective evidence-based opinions</li>
</ul><ul><li>Writing detailed reports</li>
</ul><ul><li>Leading and participating in committee and team meetings</li>
</ul><ul><li>Providing technical assistance and training</li>
</ul><ul><li>Collaborating with stakeholders</li>
</ul>
This is a remote-first position which will primarily allow you to work in your home office with an occasional need to attend in-person meetings in Nebraska. This is a non-direct care role which does not involve patient contact or nursing care.

As a valued full-time employee of Liberty Healthcare and Clinical Reviewer, you can expect:
<ul>
<li>$80,000 annual salary</li>
</ul><ul><li>Health insurance, dental insurance, vision insurance, life insurance, and disability insurance</li>
</ul><ul><li>30 days of paid time off each year for holidays, vacation, sick leave, and personal days</li>
</ul><ul><li>Health Savings Account, 401k plan, and other perks</li>
</ul>
Full details on Liberty's benefits plan are available at www.libertyhealthcare.com/upload/138.pdf
You are a good fit for this position if you possess the following:
<ul>
<li>Professionally licensed as a Registered Nurse in Nebraska</li>
</ul><ul><li>Experience providing nursing services to older adults and people who are living with developmental disabilities</li>
</ul><ul><li>Knowledge of quality assurance methodologies
</li></ul><ul><li>Outstanding analytical and report writing skills</li>
</ul><ul><li>Nebraska residency</li>
</ul>
Liberty Healthcare is an equal opportunity employer committed to diversity, equity, and inclusion. Our organization is composed of, and proudly serves, people of diverse backgrounds and abilities.

Click &ldquo;Apply&rdquo; and submit your resume for immediate consideration.</div>

Registered Nurse – Clinical Reviewer

HMSA

<div>
 
 Employment Type
 
 
 
 Full-time
 
 
 
 Exempt or Non-Exempt
 
 
 
 Exempt
 
 
 
 Job Summary
 
 
 
 
 Hybrid Work Environment - Must reside in Hawaii
 
 
 
 
 Pay Range:
 
 $59,000 to $116,000
 
 
 
 Note
 
 : Individuals typically begin between the minimum to middle of the pay range
 
 
 Under minimal supervision, conducts detailed analysis and review of precertification requests, post-service and suspended claims, by applying clinical expertise against HMSA medical and reimbursement policies, plan benefits and nationally accepted clinical guidelines to determine appropriateness of care for all HMSA lines of business.
 
 
 
 Minimum Qualifications
 
 
 
 <ul>
 <li>
 Associates degree in Nursing.
 </li>
 <li>
 Current, unrestricted Nursing License in the state of Hawaii as an RN or LPN.
 </li>
 <li>
 Two years clinical, case management or utilization management related experience.
 </li>
 <li>
 Knowledge of current standards of care to be followed for a given diagnosis and the normative values of medical tests and procedures.
 </li>
 <li>
 Strong organizational skills
 </li>
 <li>
 Good communication skills both verbally and written
 </li>
 <li>
 Analytical skills
 </li>
 <li>
 Basic knowledge of Microsoft Office applications. Including but not limited to Word, Excel, and Outlook.
 </li>
 <li>
 Currently licensed in Hawaii as an RN or LPN
 </li>
 <ul>
 <li>
 (if applicable upon hire, proof of licensure to be provided by employee or confirmed by Human Resources)
 
 </li>
 </ul>
 </ul>
 
 Duties And Responsibilities
 
 
 
 <ul>
 <li>
 Utilize medical necessity criteria from established medical policies and clinical practice guidelines to render precertification determinations as described in the Medical Management UM work plan. This detailed clinical judgment includes evaluating whether the requested service is a covered benefit under the member's health plan, is medically appropriate for the member's clinical condition or whether the request requires referral to a Medical Director for potential denial of the request. The Nurse Reviewer must follow each line of business' requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each request. Assists on inquiries from external parties such as the State Insurance Commissioner and from the Legal Department. Responsibilities include, but are not limited to:
 </li>
 <ul>
 <li>
 Demonstrate understanding and application of over 250 Guide to Benefits, Evidence of Coverage, Plan Brochure, and Member Handbook. HMSA annually updated medical and drug policies, medical protocols, National Comprehensive Cancer Network, Milliman Care Guidelines, Drugdex, etc. to determine the medical necessity of urgent and non-urgent precertification requests. Urgent requests must be completed within 72 hours and non-urgent requests within 15 calendar days.
 </li>
 <li>
 Use clinical judgment, medical necessity guidelines and plan benefits to determine approval, potential denial or alternative treatment of each urgent or non-urgent precertification request. Settings include inpatient, outpatient, in-state, out-of state and out-of country.
 </li>
 <li>
 Document clinical case summary and review outcome of each review appropriately to meet regulatory and program requirements.
 </li>
 <li>
 Review various types of services, including but not limited to:
 </li>
 <li>
 Transplants
 </li>
 <li>
 Air Ambulance
 </li>
 <li>
 Chemotherapy
 </li>
 <li>
 Clinical trials
 </li>
 <li>
 Genetic testing
 </li>
 <li>
 Cancer treatments/radiation therapy
 </li>
 <li>
 Experimental/Investigational Services/Devices
 </li>
 <li>
 New Technology
 </li>
 </ul>
 <li>
 Utilize medical necessity criteria from established medical policies and clinical practice guidelines to render precertification determinations as described in the Medical Management UM work plan. This detailed clinical judgment includes evaluating whether the requested service is a covered benefit under the member's health plan, is medically appropriate for the member's clinical condition or whether the request requires referral to a Medical Director for potential denial of the request. The Nurse Reviewer must follow each line of business' requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each request. Assists on inquiries from external parties such as the State Insurance Commissioner and from the Legal Department. Responsibilities include, but are not limited to:
 </li>
 <ul>
 <li>
 Call providers when additional clinical information is required to clarify or complete a complex precertification determination.
 </li>
 <li>
 Approve precertification requests based on clinical judgment using criteria, medical record documentation and other information received from the provider.
 </li>
 <li>
 Consult with Medical Directors on requests which do not meet clinical criteria and offer alternative covered health care options as appropriate.
 </li>
 <li>
 Consult Medical Directors on potential quality issues identified during review of medical records. Refer cases to Integrated Health Management, Pharmacy Department or Benefits Integrity Department depending on the concern.
 </li>
 </ul>
 <li>
 Evaluate suspended claims against medical records to determine the medical necessity and appropriateness of medical services, identify irregularities such as over or under-utilization of services, potential up-coding, over billing, etc.
 </li>
 <li>
 Communicate timely, accurate information either verbally, electronically or in writing using clinical judgment, knowledge of medical/reimbursement policies and plan benefits to providers, members as well as internal MM staff and other internal departments (Claims Administration, Customer Relations, Provider Contracting, etc.). For denied services, ensure the denial, benefit and appeal language are accurate and consistent with department procedures, accreditation and regulatory guidelines.
 </li>
 <li>
 Identify and refer members with specific medical and/or behavioral health needs or complex case management and collaborate with medical and behavioral case management staff. Identify and refer quality of care issues and suspected fraud, waste or abuse to the appropriate departments.
 </li>
 <li>
 Perform pre-screening assessment of incoming pre-certification requests to ensure appropriateness of review. Advises non-clinical staff on clinical and coding questions to ensure correct system processes and entries.
 </li>
 <li>
 Performs all other miscellaneous responsibilities and duties as assigned or directed.
 
 
 </li>
 </ul>
</div>

Nurse Reviewer - Clinical Review Unit

Oregon Health & Science University

<div>Department Overview:
<div>
The Critical Care Services Clinical Reviewer is the primary clinical reviewer for the ELSO registry as well as the Get With the Guidelines Stroke Registry, with additional abstraction duties as required by manager (i.e. supporting additional stroke abstraction per DNV requirements). Primary site abstraction is for OHSU. Duties include collecting concurrent and retrospective data, assuring integrity of the data collection and data entry for</div><div>
data submittal and data repository, reporting clinical outcomes and descriptive data, and integrating findings into quality improvement activities. The incumbent is responsible for accurate and timely collection and transmission of data in accordance with the guidelines established and performing data queries of that database</div><div>
as requested. The clinical reviewer will stay pro-actively appraised of any definitional, specification, or reporting changes and will actively collaborate with the registry and associated vendors. This position collaborates with the ECMO coordinators, ECMO and neurology faculty and staff, Stroke Program Manager, quality management staff, and other clinical reviewers. They will also participate as a member in applicable best practice and quality committee meetings.</div>
Function/Duties of Position:
<div>
Data Collection and abstraction</div><ul><li>
identifies patients for inclusion in applicable registries</li><li>
navigates the electronic medical record system, Epic, to abstract concurrent and retrospective data on all patients meeting national registry guidelines</li><li>
finds, reads, and comprehends H&amp;Ps, discharge summaries, progress notes, procedure notes, labs, medications, and outside medical records within Epic</li><li>
orders records from outside facilities when necessary in order to complete all the data collection fields</li><li>
collaborates with physicians and patient care teams to determine data needs and evaluate clinical outcomes</li><li>
monitors accuracy of data via automated and auditing means</li><li>
updates data collection tool as appropriate and in accordance with registry definitions, specifications, and guidelines</li><li>
enters accurate and complete data in a timely manner, using the approved software</li><li>
updates database software and data fields as necessary</li><li>
ensures timely data entry and submittal, integrity of data, and implementation of quality control measure to assure accuracy and validity</li><li>
develops and updates standard work tools</li><li>
exports data to registries per guidelines and in accordance with data security and integrity standards</li><li>
develops efficiencies to improve data collection processes</li><li>
works collaboratively to develop processes and ensure timely and complete collection and entry of data</li><li>
identifies issues related to documentation and works with appropriate clinicians and informatics staff to make appropriate improvements</li><li>
identifies issues potentially related to clinical practice and guideline adherence and brings those to the attention of the quality director, service line director, and appropriate medical director</li></ul><div>
Data Reporting and Analysis</div><ul><li>
distributes national benchmarking reports to customers as appropriate and as requested by medical directors, service line directors, and clinical staff</li><li>
develops and provides descriptive, statistical, and comparative analysis and reports of data as requested (analysis and reporting would include narrative, tabular, and graphical documentation and presentation)</li><li>
works closely with physician champion, other clinical staff, supervisor, quality management staff, and hospital staff to identify opportunities for improvement</li><li>
develops and reports standardized queries, reports, and dashboards on a quarterly basis and additional queries as requested</li><li>
prepares and presents comprehensive reports to appropriate committees, management, and other audiences within defined timeframes</li><li>
establishes effective working relationships with medical and service line leadership for reliable and meaningful data interpretation and analysis</li><li>
coordinates data inquiries to promote research activities as requested</li><li>
actively participates in accreditation visits and preparation, and provides clinical outcome and performance improvement data as required</li><li>
prepares presentations / documentation and helps present during survey visits</li><li>
presents data to DNV during onsite and intracycle visits</li></ul><div>
Communication and software maintenance</div><ul><li>
collaborates with appropriate ITG staff to address software related issues and upgrades</li><li>
acts as primary liaison with ELSO and GWTG-Stroke, and any other registries as assigned by manager</li><li>
coordinates discussions with ITG on database-related interfaces
</li><li>communicates openly and effectively with certified software vendors
</li><li>works collaboratively with vendors to troubleshoot any database and software-related issues</li><li>
communicates with database registry staff</li><li>
keeps apprised of applicable changes
</li><li>briefs and updates cardiovascular service line and quality management staff as appropriate</li></ul><div>
Other Duties as Assigned</div>
Required Qualifications:
<ul><li><div>
A Bachelor&rsquo;s degree in finance, business management or related field; AND</div></li><li><div>
Two years of industry related experience that includes project management, financial accounting, management reporting and analysis of specialized work processes standards, regulations; statistics or quantitative analysis methods and procedures, OR</div></li><li><div>
An equivalent combination of education, training and/or experience.</div></li></ul><div>
Job Related Knowledge, Skills and Abilities (Competencies):</div><ul><li>
Experience in hospital department, clinic, patient care unit, clinical research, or medical record reviewer</li><li>
Clinical chart review and abstraction experience or experience in medical database entry
</li><li>Experience working with national registries or databases</li><li>
Proficient computer skills including the use of MS Office products, basic statistical skills, and the internet.
</li><li>Experience with relational databases and data quality methods
</li><li>Clinical knowledge and understanding of patient care.</li><li>
Experience in clinical chart review and abstraction.
</li><li>Excellent verbal and written communication skills.</li><li>
Must be able to perform the essential functions of the position with or without accommodation 
</li></ul>
Preferred Qualifications:
<ul><li>Degree in healthcare related field preferred</li><li>
clinical data collection experience
</li><li>experience with the heart failure patient population</li><li>
Access and Excel proficiency
</li><li>Quality improvement and patient safety knowledge and experience</li><li>
Advanced statistic knowledge and experience</li></ul>
Why apply to OHSU?: We are Oregon's only public academic health center. In addition to caring for patients, we lead groundbreaking research. We also train the next generation of health care professionals. As Portland's largest employer, we give you opportunities to learn and advance in a system of hospitals and clinics across Oregon and Southwest Washington. All are welcome. OHSU welcomes people of all ages, ethnicities, genders, national origins, religions and sexual orientations. We are striving to build an anti-racist, multicultural institution and encourage people with diverse backgrounds to apply. To request reasonable accommodation, contact askhr@ohsu.edu</div>

Critical Care Services Clinical Reviewer (Business Data Analyst 3)

Gainwell Technologies

<div>
 It takes great medical minds to create powerful solutions that solve some of healthcare&rsquo;s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you&rsquo;ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you&rsquo;ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You&rsquo;ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development.
 
 
 
 Summary
 
 
 
 We are seeking a talented individual for the Nurse Reviewer, Associate position. In this role, you will perform clinical reviews to determine whether medical record documentation supports the need for a service, based on clinical criteria, coverage policies, and utilization and practice guidelines as defined by the review methodologies specific to the contract. This involves accessing proprietary systems to audit medical records, accurately documenting findings, and providing policy and regulatory support for determinations.
 
 
 
 Essential Job Functions
 
 
 
 <ul>
 <li>
 Review and interpret medical records, comparing them against criteria to determine the appropriateness and reasonableness of care. Apply critical thinking and decision-making skills to assess whether the documentation supports the need for the service while maintaining production goals and quality standards.
 </li>
 <li>
 Document decisions and rationale to justify review findings or no findings.
 </li>
 <li>
 Determine approvals or initiate referrals to the physician consultant, processing their decisions while ensuring denials are explained in sufficient detail and completed within contractual deadlines.
 </li>
 <li>
 Perform prior authorization, precertification, and retrospective reviews, and prepare decision letters as needed in support of the utilization review contract.
 </li>
 <li>
 Maintain current knowledge of clinical criteria guidelines and complete required CEUs to maintain RN licensure.
 </li>
 <li>
 Attend training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations.
 </li>
 <li>
 Actively cross-train to perform reviews of multiple claim types, providing a flexible workforce to meet client needs.
 
 
 </li>
 </ul>
 
 What We're Looking For
 
 
 
 <ul>
 <li>
 Active, unrestricted RN licensure from the United States and in your state of primary residence; an active compact multistate RN license as defined by the Nurse Licensure Compact (NLC) is also required.
 </li>
 <li>
 3+ years of clinical experience in an inpatient hospital setting.
 </li>
 <li>
 1+ years of experience in utilization review or claims auditing.
 </li>
 <li>
 Experience using Milliman or InterQual criteria is preferred.
 </li>
 <li>
 Demonstrated proficiency in computer skills, including Microsoft Windows, Outlook, Excel, Word, PowerPoint, internet browsers, and typing.
 
 
 </li>
 </ul>
 
 What You Should Expect In This Role
 
 
 
 <ul>
 <li>
 Home-based position; you must have a work location within the continental U.S.
 </li>
 <li>
 Must provide a high-speed internet connection and a work environment free from distractions.
 </li>
 <li>
 Full-time schedule during normal business hours is required, as the role involves frequent interactions with the team and other departments.
 </li>
 <li>
 May be required to work extended hours for special business needs.
 </li>
 <li>
 May be required to travel up to 10% of the time based on business needs.
 
 
 </li>
 </ul>
 This position is for pipeline purposes, and we welcome applications on an ongoing basis.
 
 
 The pay range for this position is $70,000.00 - $80,000.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You&rsquo;ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.
 
 
 We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You&rsquo;ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings.
 
 
 
 Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. Gainwell Technologies defines &ldquo;wages&rdquo; and &ldquo;wage rates&rdquo; to include &ldquo;all forms of pay, including, but not limited to, salary, overtime pay, bonuses, stock, stock options, profit sharing and bonus plans, life insurance, vacation and holiday pay, cleaning or gasoline allowances, hotel accommodations, reimbursement for travel expenses, and benefits.
 
</div>

Nurse Reviewer Associate- Remote

Blue Cross Blue Shield

<div><h1 class="jobSectionHeader">Summary
 
</h1>We are currently hiring for an RN Medical Reviewer III to join BlueCross BlueShield of South Carolina. In this role as an RN Medical Reviewer III, you will perform medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines, document decisions using indicated protocol sets or clinical guidelines, and provide support and review of medical claims and utilization practices.
<h1 class="jobSectionHeader"> 
Description 
 
</h1>Location:
This position is full-time (40 hours/week) Monday-Friday, working an 8-hour shift between 6:00am &ndash; 5:00pm and will be fully remote after 1-2 weeks of on-site training in Columbia, SC.
What You&rsquo;ll Do:
<ul><li>Performs medical claim reviews for one or more of the following: claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, correct coding for claims/operations. Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines. Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement. Monitors process&rsquo;s timeliness in accordance with contractor standards. Documents medical rationale to justify payment or denial of services and/or supplies.
</li><li>Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
</li><li>Participates in quality control activities in support of the corporate and team-based objectives. Provides guidance, direction, and input as needed to LPN team members. Provides education to non-medical staff through discussions, team meetings, classroom participation, and feedback. Assists with special projects and specialty duties/responsibilities as assigned by management.
</li></ul>To Qualify for This Position, You'll Need the Following:
<ul><li>Required Education: Associates in a job-related field
</li><li>Degree Equivalency: Graduate of Accredited School of Nursing
</li><li>Required Experience: 2 years clinical plus 1 year utilization/medical review, quality assurance, or home health, OR 3 years clinical. FOR PALMETTO GBA (CO. 033) ONLY: 2 years clinical experience plus 2 years utilization/medical review, quality assurance, or home health experience.
</li><li>Required Skills and Abilities: Working knowledge of managed care and various forms of health care delivery systems; strong clinical experience to include home health, rehabilitation, and/or broad medical surgical experience. Knowledge of specific criteria/protocol sets and the use of the same.
</li><li>Working knowledge of word processing software.
</li><li>Ability to work independently, prioritize effectively, and make sound decisions.
</li><li>Good judgment skills.
</li><li>Demonstrated customer service and organizational skills.
</li><li>Demonstrated oral and written communication skills.
</li><li>Ability to persuade, negotiate, or influence others.
</li><li>Analytical or critical thinking skills.
</li><li>Ability to handle confidential or sensitive information with discretion.
</li><li>Required Software and Tools: Microsoft Office.
</li><li>Required Licenses and Certificates: Active, unrestricted RN licensure from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), OR, current active, unrestricted licensure/certification from the United States and in the state of hire in specialty area as required by hiring division/area.
</li></ul>What We Prefer You to Have:
<ul><li>Preferred Work Experience: Well-rounded adult, clinical experience (i.e., medical-surgical, ER, critical care)
</li><li>Preferred Skills and Abilities: Knowledge of spreadsheet and database software.
</li><li>Knowledge of Medicare and/or regulations/policies/instructions/provisions, home health, and/or system/processing procedures for medical review.
</li><li>Preferred Software and Other Tools: Working knowledge of Microsoft Excel, Access, or other spreadsheet database software.
</li></ul>Our Comprehensive Benefits Package Includes the Following:
We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 days of employment.
<ul><li>Subsidized health plans, dental and vision coverage
</li><li>401k retirement savings plan with company match
</li><li>Life Insurance
</li><li>Paid Time Off (PTO)
</li><li>On-site cafeterias and fitness centers in major locations
</li><li>Education Assistance
</li><li>Service Recognition
</li><li>National discounts to movies, theaters, zoos, theme parks and more
</li></ul>What We Can Do for You:
We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.
What To Expect Next:
After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements.
Equal Employment Opportunity Statement
BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.
We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.
If you need special assistance or an accommodation while seeking employment, please email mycareer.help@bcbssc.com or call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.
We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information .
Some states have required notifications. Here's more information .</div>

RN Medical Reviewer III (W@H South Carolina)

Staffing Solutions Organization LLC

<div>
 
 
 Ensure Quality Care Across Illinois&mdash;One Review at a Time.
 
 
 
 
 
 
 
 Nurse Reviewer &ndash; Illinois
 
 
 
 
 Location:
 
 Remote with on‑site visits across Illinois
 
 
 
 
 
 
 Position Overview
 
 
 
 The Nurse Reviewer conducts provider compliance reviews to ensure adherence to state regulations, quality standards, and program requirements. This role includes conducting onsite visits, evaluating documentation, and determining provider compliance. The Nurse Reviewer works independently, exercises sound judgment, and provides recommendations that guide provider improvement and support statewide oversight efforts.
 
 
 
 
 
 
 Duties &amp; Responsibilities
 
 
 <ul>
 <li>
 Build and maintain effective relationships with providers and users to support high‑quality customer service.
 </li>
 <li>
 Evaluate providers for compliance with applicable state and program regulations.
 </li>
 <li>
 Coordinate and schedule on‑site provider visits; clearly communicate visit requirements.
 </li>
 <li>
 Conduct compliance interviews with providers and gather all necessary information.
 </li>
 <li>
 Review provider documentation, policies, and business practices for regulatory alignment.
 </li>
 <li>
 Collect, organize, and submit documentation supporting compliance findings.
 </li>
 <li>
 Utilize technology and web‑based systems to convert paper documentation to electronic format.
 </li>
 <li>
 Conduct in‑person assessments of provider sites to evaluate compliance with oversight requirements.
 </li>
 <li>
 Summarize on‑site visit findings accurately and professionally.
 </li>
 <li>
 Exercise independent judgment to evaluate compliance and make final determinations based on documented evidence.
 </li>
 <li>
 Identify deficiencies and recommend appropriate next steps to support provider improvement.
 </li>
 <li>
 Analyze trends in non‑compliance and identify gaps in provider business processes.
 </li>
 <li>
 Provide timely recommendations and updates to the Supervisor.
 </li>
 <li>
 Maintain HIPAA standards and confidentiality at all times.
 </li>
 <li>
 Perform other duties as assigned.
 </li>
 </ul>
 
 
 
 
 
 Required Skills
 
 
 <ul>
 <li>
 Strong interpersonal skills with the ability to relate well to staff and providers.
 </li>
 <li>
 Active listening and effective communication skills.
 </li>
 <li>
 Proficiency in MS Word, Excel, Outlook, and web‑based applications.
 </li>
 <li>
 Process‑oriented and results‑driven work approach.
 </li>
 <li>
 Ability to foster teamwork and collaborate across levels of management and staff.
 </li>
 <li>
 Ability to work independently and within a team environment.
 </li>
 <li>
 Excellent written and verbal communication skills and customer‑service techniques.
 </li>
 <li>
 High accuracy, strong attention to detail, and commitment to quality.
 </li>
 <li>
 Proven ability to meet deadlines and follow strict standards.
 </li>
 <li>
 Ability to travel regularly to provider sites across Illinois.
 </li>
 </ul>
 
 
 
 
 
 Qualifications
 
 
 
 
 Education
 
 
 <ul>
 <li>
 Bachelor&rsquo;s degree in any field (Nursing preferred)
 </li>
 </ul>
 
 
 Experience
 
 
 <ul>
 <li>
 Minimum
 
 2 years of clinical experience
 
 working with critical care providers, public health providers, or providers serving children, older adults, individuals with traumatic brain injury, or individuals with developmental disabilities.
 </li>
 <li>
 Minimum
 
 1 year of experience
 
 conducting quality assurance reviews.
 </li>
 </ul>
 
 
 Certification
 
 
 <ul>
 <li>
 Active Illinois Registered Professional Nurse (RN) license required.
 </li>
 </ul>
 
 
 
 
 
 Working Conditions
 
 
 <ul>
 <li>
 Remote work with
 
 2&ndash;3 on‑site provider visits per week
 
 throughout the state of Illinois.
 </li>
 </ul>
 
 
 
 
 
 Benefits (Through SSO)
 
 
 
 SSO offers a competitive benefits package that supports your health, financial well‑being, and long‑term growth, including:
 
 <ul>
 <li>
 Medical, dental, and vision insurance
 </li>
 <li>
 401(k) with discretionary employer match
 </li>
 <li>
 Paid time off and holidays
 </li>
 <li>
 Flexible spending accounts
 </li>
 <li>
 Additional employee perks
 </li>
 </ul>
 
 
 
 
 
 Keyword Search Terms
 
 
 
 Nurse Reviewer, RN Reviewer, Provider Management Specialist, Compliance Nurse, Healthcare Quality Review, Provider Compliance, Medicaid Compliance, Clinical Reviewer, Illinois RN, Site Visit Nurse, Healthcare Auditor, Public Health Nursing, QA Nurse, Provider Monitoring.
 
</div>

Nurse Reviewer

Search 10000+ Clinical nurse reviewer jobs near you this April. New roles added regularly across leading industries. Apply today.

10000 clinical nurse reviewer jobs Near Me

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RN Medical Reviewer III (W@H South Carolina)

Nurse Reviewer