Senior Medical Reviewer

Role Overview

• Acts as Team Lead for specialty programs, medical review, utilization management, and case management areas
• Provides leadership/guidance/direction/training to staff
• Maintains a working knowledge of unit functions and the ability to interpret to new hires
• Acts as a resource for staff/external entities troubleshooting as well as resolving issues
• Keeps manager informed of any problems/issues that need resolving
• Assists management with monitoring workflow and workloads
• Participates in departmental quality reviews
• Follows a process to ensure quality plan is adhered to
• Gives/receives feedback regarding medical review decision making and technical claims processing issues
• Ensures that quality work instructions/forms/documents are developed/revised as needed
• Provides quality service and communicates effectively with external/internal customers in response to inquiries
• Obtains information from internal departments, providers, government, and/or private agencies, etc. to resolve discrepancies/problems
• Participates in compliance initiatives and other directed activities
• Participates/oversees special projects as requested by management

Requirements

• Associate Degree
• Nursing OR Graduate of Accredited School of Nursing
• Four years of clinical OR Two years of clinical and two years of medical review/utilization review OR Combination of health plan, clinical, and business experience totaling four years
• ESRD/renal dialysis experience preferred
• Five or more years’ clinical, quality management, or leadership experience as a registered nurse in a Dialysis setting preferred
• Three or more years’ education/training/consulting experience related to Dialysis services preferred
• Three or more years’ experience in quality management coordination related to Dialysis services preferred
• Working knowledge of managed care and various forms of health care delivery systems
• Strong clinical experience to include home health, rehabilitation, and/or broad medical surgical experience
• Knowledge of specific criteria/protocol sets and the use of the same
• Working knowledge of word processing and spreadsheet software
• Ability to work independently, prioritize effectively, and make sound decisions
• Good judgment skills
• Demonstrated customer service, organizational, and presentation skills
• Demonstrated proficiency in spelling, punctuation, and grammar skills
• Demonstrated oral and written communication skills
• Ability to persuade, negotiate, or influence others
• Analytical or critical thinking skills
• Ability to handle confidential or sensitive information with discretion
• Ability to lead/direct/motivate others
• Active, unrestricted RN licensure from the United States and in the state of hire, OR active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact NLC

Benefits

• Health insurance
• 401(k) matching
• Paid time off
• Flexible work arrangements
• Professional development