Nurse - Clinical Review (Medical)

TL;DR

Nurse - Clinical Review (Medical): Performing utilization reviews and determining medical necessity criteria for cases with an accent on compliance with state and federal regulations. Focus on facilitating escalated case resolutions, collaborating with healthcare providers, and ensuring adherence to HIPAA and URAC/NCQA standards.

Location: Remote (Must have an active unrestricted RN, LPN/LVN license in the U.S.)

Salary: $65,000 (LVN/LPN) – $75,000 (RN) annually

Company

hirify.global is an Agentic AI-powered leader in intelligent operations and transformation serving global clients across various industries including Healthcare and Insurance.

What you will do

• Perform utilization reviews to determine medical necessity based on agreed policies and governing body criteria.
• Facilitate the resolution of escalated cases requiring special handling.
• Collaborate with client personnel, providers, and members to resolve concerns and facilitate the review process.
• Maintain detailed written documentation in accordance with company and regulatory policies.
• Ensure consistency in implementation of policy and regulatory requirements in collaboration with Nursing Management.
• Adhere to HIPAA, state, and federal regulations pertaining to clinical programs.

Requirements

• Active unrestricted RN, LPN/LVN license in the state or territory of the U.S.
• Minimum of 2 years experience in utilization review, case management, or clinical quality improvement.
• RN, LPN/LVN graduate from an accredited school of nursing.
• Proficiency in Microsoft Office (Word, Excel, PowerPoint) and ability to adapt to healthcare-specific software.
• Working knowledge of National Coverage Determination (NCD), Local Coverage Determination (LCD), and insurance terminology.
• Ability to work according to CST time zone schedules (Training: 8:00 AM – 4:30 PM; Regular: 10:30 AM – 7:00 PM).

Culture & Benefits

• Medical, dental, and vision insurance.
• Paid time off (PTO), holidays, and sick leave.
• 401(k) with company match or other retirement plan.
• Life and AD&D Insurance.
• Employee Assistance Program.