Clinical Review Nurse

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Clinical Review Nurse (RN) (WORK FROM HOME) needed for a remote contract opportunity with Yoh’s client!

Conducts investigations and reviews of member and provider medical necessity grievances and appeals. Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity. Extrapolates and summarizes medical information for Medical Director, consultants or other external review. Apply clinical medical necessity guidelines, policy and procedures, and EOC benefit guidelines. Prepares recommendations to either uphold or overturn and forwards to Medical Director for approval. Ensures that appeals, grievances and disputes are resolved timely to meet regulatory requirements. Apply expedited criteria to recommend the appropriateness of urgent requests. Documents and logs appeal/grievance/dispute information on relevant tracking systems. Generates written correspondence to providers, members and regulatory entities. Interact with members, providers and/or other staff to ensure resolution of plan recommendations. Recognize potential quality of care concerns and refer to the Medical Director for review. Utilize leadership skills and serves as a subject matter expert for appeals/grievances/disputes/quality of care issues and is a resource for clinical and non clinical team members in expediting the resolution of outstanding issues. Perform other duties and special projects as assigned.