medical reviewer

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)

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

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)

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

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

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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