clinical 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

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)

Tanaq Health

<div>
 
 Description
 
 
 
 
 Overview
 
 
 
 Tanaq Support Services (TSS) delivers professional, scientific, and technical services and information technology (IT) solutions to federal agencies in health, agriculture, technology, and other government services. TSS is a subsidiary of the St. George Tanaq Corporation, an Alaskan Native Corporation (ANC) committed to serving Federal customers while also giving back to the Tanaq native community and shareholders.
 
 
 
 About The Role
 
 
 
 We are seeking a
 
 Clinical Appeals Reviewer
 
 to support a contract with our federal client. The Clinical Appeals Professional performs complex (senior-level) work. Provides dissatisfied parties with the opportunity to present documentation to demonstrate why an appeal should be allowed. Provides an independent second level determination based on the documentation, facts, laws, regulations, and guidelines. Works under general supervision, with moderate latitude for the use of initiative and independent judgment. Qualified candidates must be licensed health care professionals capable of rendering independent clinical judgment, including but not limited to Registered Nurses (RN), Physical Therapists (PT), Occupational Therapists (OT), and Respiratory Therapists (RT).
 
 
 This is a remote position that can be based anywhere in the United States. Must be able to work on a rotating schedule on weekends and holidays.
 
 
 
 Responsibilities
 
 
 
 <ul>
 <li>
 Reviews medical records/case files, writes reconsideration decision letters that are clear, concise, and impartial, and support the determination made, and documents the review.
 </li>
 <li>
 Makes sound, independent decisions based on medical evidence in accordance with statutes, regulations, rulings, and policy.
 </li>
 <li>
 Responds to and ensures that all appeal issues raised by the beneficiary/patient, representative, and provider/supplier have been addressed.
 </li>
 <li>
 Provides a fair and impartial decision based on current evidence, regulations, policies, and procedures.
 </li>
 <li>
 Conducts research using online federal regulations, contract policy, standards of medical practice, contract manuals, coverage issues manuals, medical literature, and other related resources to complete an accurate and well-supported decision.
 </li>
 <li>
 Stays abreast of changes in regulations, medical and healthcare practices, policies, and procedures.
 </li>
 <li>
 Participates in case-specific verbal discussions.
 </li>
 <li>
 Conducts reviews of appeals/disputes with multiple beneficiaries/services in one case.
 </li>
 <li>
 Plans responses to statistical analysis challenges with assistance from statisticians.
 </li>
 <li>
 Attends meetings and participates in workgroups at management's direction.
 </li>
 <li>
 Conducts quality reviews, as needed.
 </li>
 <li>
 Serves as a subject matter expert.
 </li>
 <li>
 Mentors and/or trains staff.
 </li>
 <li>
 May conduct quality reviews and audits.
 </li>
 <li>
 Participates in special projects and performs other duties as assigned.
 
 
 </li>
 </ul>
 
 Requirements
 
 
 
 
 Required Skills and Experience
 
 
 
 <ul>
 <li>
 Three (3) years of experience in medical dispute resolution, Medicare appeals, medical review, clinical work, or related healthcare roles.
 </li>
 <li>
 Healthcare Professional with experience in Nursing, Physical Therapy, Respiratory Therapy, or Occupational Therapy experience.
 </li>
 <li>
 Demonstrated experience writing or making medical necessity decisions.
 </li>
 <li>
 Proficiency in research techniques, medical terminology, and analyzing and interpreting policies, along with knowledge of state and federal laws and regulations.
 </li>
 <li>
 Must have experience and working knowledge of the Medicare program, including coverage and payment rules.
 </li>
 <li>
 Experience with Medicare regulations, claims processing, and the medical review process, as well as applicable laws, rules, and regulations.
 </li>
 <li>
 Prioritize and organize work tasks to handle multitasking and meet deadlines.
 </li>
 <li>
 Ability to prepare correspondence and documents using correct spelling, grammar, and punctuation; proofreading and reviewing documents for clarity and consistency.
 </li>
 <li>
 Practice logic and reasoning to identify problems, verify facts, and reach valid conclusions.
 </li>
 <li>
 Experience in making decisions that support business objectives and goals.
 </li>
 <li>
 Ability to identify and resolve problems or refer issues appropriately.
 </li>
 <li>
 Communicate effectively verbally and in writing.
 </li>
 <li>
 Adapt to the needs of internal and external customers.
 </li>
 <li>
 Show integrity and ethical behavior, respect confidentiality, business ethics, and organizational standards.
 </li>
 <li>
 Ensure compliance with company policies, procedures, and guidelines, including cybersecurity, regulatory, contractual, and accreditation entities.
 </li>
 <li>
 Experience directly relevant to Medicare managed care appeals or utilization management activities, preferred.
 </li>
 <li>
 Must have resided in the United States for a minimum of three (3) years out of the last five (5) years. This is a contractual requirement.
 </li>
 <li>
 Must possess a valid driver's license with a clear and satisfactory driving record.
 </li>
 <li>
 Ability to obtain and maintain public trust clearance and customer approval.
 </li>
 <li>
 Must be legally authorized to work in the United States without the need for employer sponsorship, now or at any time in the future.
 
 
 </li>
 </ul>
 
 Education and Training
 
 
 
 <ul>
 <li>
 Associate's degree or 60 or more credit hours towards a Bachelor&rsquo;s degree from an accredited college or university in healthcare or related discipline.
 </li>
 <li>
 Additional experience in Medicare appeals, medical review, clinical, or other related experience in a healthcare setting may be substituted for an Associate&rsquo;s degree on a year per year basis. (Experience requirements may be satisfied by full-time experience or the prorated part-time equivalent.)
 
 
 </li>
 </ul>
 
 Physical Requirements And Work Environment
 
 
 
 <ul>
 <li>
 Requires working in an office/cubicle environment; sitting, standing, walking, bending, twisting, and/or reaching.
 </li>
 <li>
 Prolonged periods of sitting at a desk and working on a computer. May need to lift 25 pounds occasionally.
 </li>
 <li>
 May require the ability to operate a motor vehicle and travel by motor vehicle and commercial airline. May require overnight travel. Travel may be less than 5% annually.
 
 
 </li>
 </ul>
 
 Who We Are
 
 
 
 Tanaq Management Services (TMS) is a public health contractor, certified 8(a) business, owned by St. George Tanaq Corporation, an Alaska Native Corporation. (ANC). We listen to our stakeholders and leverage our science, technology, communication, and program expertise to understand and provide feedback as we develop solutions.
 
 
 
 Our Commitment to Non-Discrimination
 
 
 
 Tanaq is an Equal Employment Opportunity Employer. All qualified applicants will receive consideration for employment without regard to disability, status as a protected veteran or any other status protected by applicable federal, state, or local law. Tanaq complies with the Drug-free Workplace Act of 1988 and E-Verify.
 
 
 If you are an individual with a disability and need assistance completing any part of the application process, please email accommodation@tanaq.com to request a reasonable accommodation. This email is for accommodation requests only and cannot be used to inquire about the status of applications.
 
 
 
 Notice on Candidate AI Usage
 
 
 
 Tanaq is committed to ensuring a fair and competitive interview process for all candidates based on their experience, skills and education. To ensure the integrity of the interview process, the use of artificial intelligence (AI) tools to generate or assist with responses during phone, in person and virtual interviews is not allowed. However, candidates who require a reasonable accommodation that may involve AI are required to contact us prior to their interview at accommodation@tanaq.com.
 
 
 
 To Apply For This Positions, Visit
 
 
 
 https://recruiting.paylocity.com/Recruiting/Jobs/Details/4071254
</div>

Clinical Appeals Reviewer (Licensed Healthcare Professional)

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

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

Staffing Solutions Organization LLC (SSO)

Staffing Solutions Organization LLC (SSO), an affiliate of Public Consulting Group LLC (PCG), is focused on delighting clients with world-class managed staffing and talent consulting services. SSO is committed to a diverse workforce, which is a reflection of our clients and the people they serve.
 
Nurse Reviewer – 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 & 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’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 2–3 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.
 
Compensation for roles at Staffing Solutions Organization LLC (SSO) varies depending on a wide array of factors including, but not limited to, the specific office location, role, skill set, and level of experience. As required by applicable law, SSO provides a reasonable range of compensation for this role. In addition, SSO provides a range of benefits for this role.
 
Applicants must be authorized to work in the U.S. This position is not eligible for work authorization sponsorship (including H-1B sponsorship) by SSO and under the federal laws relating to the F-1 STEM EAD program, this position is not eligible to support a STEM EAD extension application.
 
All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, gender identity, marital status, age, national origin, protected veteran status, or disability. Staffing Solutions Organization LLC is an E-Verify participant.

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