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Clinical Reviewer

1 month ago

Fargo, North Dakota, United States NORIDIAN HEALTHCARE SOLUTIONS, LLC Full time
Clinical Reviewer Job Description

Noridian Healthcare Solutions, LLC is seeking a skilled Clinical Reviewer to join our team.

Job Summary

The Clinical Reviewer evaluates medical records to determine compliance with applicable guidelines and standards of care. This role requires strong clinical expertise and effective communication skills to document decisions and rationale, and communicate results with stakeholders.

Key Responsibilities
  • Reviews and analyzes medical records to determine compliance with regulations and standards of care.
  • Applies accurate and independent coverage and payment decisions using consistent evaluation standards.
  • Communicates decisions and provides education to stakeholders through various methods.
  • Determines recommendations for actions based on analysis of review results.
  • Prioritizes workload depending on business need and direction.
  • Identifies and communicates potential fraud, waste, and abuse using established work instructions.
  • Collaborates and communicates with peers and leaders.
  • Participates in team quality and calibration review processes.
  • Serves as a mentor to peers.
  • May prepare documents for, and participate in, legal hearings.
Requirements
  • Current, active, unrestricted RN license in state of practice.
  • 2 years' clinical experience.
  • 1 year Microsoft Office experience.
  • Strong verbal and written communication skills.
  • Strong computer experience.
Preferred Qualifications
  • Bachelor's degree in Nursing (BSN, BAN, etc.).
  • 1 year experience evaluating medical records applying clinical expertise to determine compliance with applicable guidelines and standards of care.
  • 1 year experience utilization review or case management.
  • 1 year experience educating external customers.
  • 1 year experience leading projects, initiatives, or processes.
  • Strong prioritization, problem solving, and organizational skills.
  • Strong attention to detail.
  • Knowledge of coding.
  • Microsoft proficiency.
  • Strong business writing experience.
Work Environment

This is an office environment that requires prolonged sitting and telephone use. The ability to read, hear, speak, keyboard, reason, communicate effectively, and problem solve is essential.

Equal Employment Opportunity

Noridian Healthcare Solutions, LLC is an equal opportunity employer and welcomes applications from diverse candidates.

Salary Range

The salary range for this position is $52,000 - $85,724.33 per year, plus an incentive plan and lifestyle benefit of $50 per month.