Job Description
Clinical Review Nurse (RN) (WORK FROM HOME) needed for a remote contract opportunity with Yoh’s client!
Top Skills You Should Possess:
- Minimum three years acute care clinical experience required
- Minimum two years of experience in appeals and grievances casework required
What You’ll Be Doing:
- 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.
What You Need to Bring to the Table:
- Active California Registered RN license required.
- Bachelor’s degree preferred
- Minimum three years acute care clinical experience required
- Minimum two years of experience in appeals and grievances casework required
- Utilization Management or Quality Management experience preferred
- Experience using standardized clinical guidelines preferred
- Milliman Care Guidelines (MCG), Managed Care and NCQA experience preferred
- Have a cleared TB test prior to or within seven days of hire.
- Current CPR and first aid card prior to or within six months of hire is preferred.
- Excellent verbal and written communication skills.
- Ability to work within guidelines and protocols to achieve decisions independently.
- Excellent computer skills.
Any pay ranges displayed are estimations which may have been provided by job boards. Actual pay is determined by an applicant's experience, technical expertise, and other qualifications as listed in the job description. All qualified applicants are welcome to apply.
What’s In It For You?
We welcome you to be a part of the largest global staffing companies to meet your career aspirations. Yoh’s network of client companies has been employing professionals like you for over 65 years in the U.S., UK and Canada. Join Yoh’s extensive talent community that will provide you with access to Yoh’s vast network of opportunities.
- Medical, Dental & Vision Benefits
- 401K Retirement Saving Plan
- Life & Disability Insurance
- Direct Deposit & weekly EPayroll
- Employee Discount Programs
- Referral Bonus Programs
What are you waiting for? Apply Now!
Recruiter: Arlet Khachikyan
Yoh makes finding and applying for jobs simple. Partner with Yoh to find the right opportunities across multiple industries in the US and UK. Estimated Min Rate : $46.31
Estimated Max Rate : $66.16
Note: Any pay ranges displayed are estimations. Actual pay is determined by an applicant's experience, technical expertise, and other qualifications as listed in the job description. All qualified applicants are welcome to apply.
Yoh, a Day & Zimmermann company, is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
Visit to contact us if you are an individual with a disability and require accommodation in the application process.
For California applicants, qualified applicants with arrest or conviction records will be considered for employment in accordance with the Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act. All of the material job duties described in this posting are job duties for which a criminal history may have a direct, adverse, and negative relationship potentially resulting in the withdrawal of a conditional offer of employment.
Job Tags
Contract work, Immediate start, Remote job,