Clinical Care Reviewer II
WFA Digital Insight
The demand for skilled clinical care reviewers has grown significantly in the remote job market, with a 25% increase in job postings over the past year. As healthcare services continue to evolve, professionals with strong Excel skills and clinical expertise are in high demand. With the rise of telehealth and remote patient care, companies like name are seeking talented individuals to join their teams. In this role, you'll have the opportunity to work with a collaborative team, utilizing your skills to make a meaningful impact on patient care. Before applying, candidates should be aware of the importance of staying up-to-date on state and federal regulations governing healthcare services.
Job Description
About the Role
The Clinical Care Reviewer II plays a vital role in ensuring the delivery of high-quality healthcare services to patients. As a key member of the care management team, you will be responsible for conducting medical necessity reviews, coordinating care transitions, and collaborating with healthcare providers to facilitate seamless patient care. Your expertise in utilizing Excel to analyze data and track patient outcomes will be essential in this role. The care management team is a dynamic and supportive environment, where you will have the opportunity to work closely with other healthcare professionals to achieve common goals.In this role, you will be working closely with the medical director, care coordination team, and other stakeholders to ensure that patients receive the necessary care and support. Your strong communication skills and ability to work effectively in a team environment will be essential in building strong relationships with healthcare providers and patients.
What You Will Do
- Conduct prospective, concurrent, and retrospective reviews of medical necessity for authorization of healthcare services
- Collaborate with care coordination team to facilitate transitions to appropriate levels of care
- Engage with medical director to seek additional clinical expertise when needed
- Maintain knowledge of state and federal regulations governing healthcare services
- Identify and refer quality issues to Quality Improvement
- Provide guidance to non-clinical staff and LPN clinical staff as needed
- Attend medical advisement and state hearing meetings as requested
- Assist team leader with special projects or research as requested
- Perform other job-related duties as requested
- Utilize Excel to analyze data and track patient outcomes
- Develop and maintain reports to track key performance indicators
- Collaborate with healthcare providers to develop care plans
- Coordinate with care coordination team to facilitate patient discharge planning
- Communicate effectively with patients, families, and healthcare providers
- Stay up-to-date on changes in healthcare regulations and policies
What We Are Looking For
- Associates of Science (A.S) degree in nursing or related field
- Completion of an accredited registered nursing (RN) degree program
- Three years of clinical experience, preferably in med/surgical, emergency, or home health care
- Utilization Management/Utilization Review experience preferred
- Medicaid/Medicare/Commercial experience preferred
- Strong proficiency in Excel and ability to navigate clinical platforms
- Effective oral and written communication skills
- Ability to work independently and within a team environment
- Attention to detail and strong organizational skills
- Current, unrestricted Registered Nurse (RN) licensure in state(s) of practice
- MCG Certification or willingness to obtain within six months of hire
Nice to Have
- Experience with care management software and electronic health records
- Knowledge of state and federal regulations governing healthcare services
- Certification in case management or related field
- Bilingual or multilingual skills
- Experience working in a fast-paced, dynamic environment
Benefits and Perks
- Competitive salary range
- Opportunity to work with a collaborative and supportive team
- Comprehensive benefits package, including health, dental, and vision insurance
- 401(k) retirement plan with company match
- Paid time off and holidays
- Remote work arrangement with flexible scheduling
- Professional development opportunities, including training and education assistance
- Recognition and reward programs for outstanding performance
How to Stand Out
- Be prepared to provide specific examples of your experience with utilization management and review, as well as your proficiency in Excel.
- Highlight your ability to work independently and as part of a team, as well as your strong communication and organizational skills.
- Research the company's mission and values, and be prepared to discuss how your skills and experience align with them.
- Consider obtaining certifications such as MCG or case management to increase your competitiveness for the role.
- Be prepared to discuss your experience with care management software and electronic health records, and how you have utilized these tools to improve patient outcomes.
- Be prepared to ask questions during the interview, such as what a typical day in the role looks like, and what opportunities there are for professional development and growth.
This is a remote position listed on WFA Digital, the platform for professionals who work from anywhere. Browse more remote jobs across all categories.