Clinical Nurse Specialist

**REMOTE** Clinical Review Nurse - Concurrent Review

12 months contract

This candidate will be working with the IL and MI Medicaid product, Meridian.

Position Purpose:

Drafts correspondence letters based on review outcomes in accordance with National Committee for Quality Assurance (NCQA) standards. Works with senior management to identify and implement opportunities for improvement.

• Performs clinical review of outcomes including creating and editing denial letters with the correspondence team based on denial determinations in accordance with National Committee for Quality Assurance (NCQA) standards
• Contributes to correspondence letter template creation and maintenance with the correspondence team
• Investigates denials through comprehensive review of clinical documentation, clinical criteria/guidelines, and policy, including insurance rejections due to coding issues and provides supplemental information to resolve denial claims
• Assists with issues and/or questions related to correspondence with the state, local, and federal agencies including third party payer to ensure issues are resolved in a timely manner
• Maintains and monitors cases to ensure timely resolution and logs of actions and/or decisions are appropriately documented
• Coordinates with interdepartmental teams on training needed within the utilization management team based on trends
• Provides feedback to leadership to improve clinical processes and procedures to prevent recurrences based on industry best practices
• Performs other duties as assigned
• Complies with all policies and standards

Requirements:

• Requires graduated from an accredited school of nursing or Associate or bachelor's in nursing.