Clinical Review Nurse Specialist

4 weeks ago


Mechanicsburg, Pennsylvania, United States Novitas Solutions Full time
Job Summary

We are seeking a highly skilled Clinical Review Nurse to join our team at Novitas Solutions. As a Clinical Review Nurse, you will play a critical role in reviewing and making medical determinations on health claims to ensure compliance with national and local policies, as well as accepted medical standards of care.

Key Responsibilities
  • Review and analyze pre and post-pay complex healthcare claims from a medical perspective
  • Conduct clinical review work as assigned, providing guidance to other team members and accurately interpreting and applying broad CMS guidelines to specific situations
  • Identify providers needing education and individually educate providers who are subject to medical review processes
  • Participate in special projects as assigned
Requirements
  • High School Diploma or GED
  • 2 years' clinical experience
  • Excellent written and oral communication skills
  • Demonstrated experience with evaluating medical and healthcare delivery issues
  • Strong computer skills to include Microsoft Office proficiency
  • Valid unrestricted Registered Nurse (RN) license
Preferred Qualifications
  • Bachelor of Science in Nursing (BSN)
  • Insurance industry experience

This opportunity is open to remote work in the following approved states: AL, AK, FL, GA, ID, IN, IO, KS, KY, LA, MS, NE, NC, ND, OH, PA, SC, TN, TX, UT, WV, WI, WY. Specific counties and cities within these states may require further approval.

We are an Equal Opportunity Employer/Protected Veteran/Disabled.



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