RN Clinical Reviewer – IDR

Job Description

Conduct medical reviews through the appeal stage, including chart screening, regulatory guidance compilation, insurer requirements research, worksheet completion, and final determination preparation. Serve as a resource for administrative and clinical staff, offering training, problem-solving support, and determination clarification. Provide technical assistance and engage in staff huddles. Participate in collaborative training programs. Undertake additional activities as required to support the team and improve review processes.

Qualifications

1. Education: A Bachelor's degree in Nursing or completion of an approved RN program. 2. Licensure: Must hold a current New York State RN license. 3. Experience: - A minimum of 3 years of experience in a Med-Legal review setting is essential. - Must have 1-3 years of experience in acute care utilization review/appeals. 4. Technical Skills: Proficiency with electronic medical records and strong research capabilities. 5. Soft Skills: Excellent written and verbal communication skills, the ability to work independently, flexibility, innovation, ability to meet deadlines in sensitive environments, and strong collaborative and problem-solving skills.

Benefits

- Competitive Compensation: $50/hr. - Comprehensive Benefits: - Enjoy one week of paid vacation, which accrues after three months of employment, increasing to two weeks of paid vacation from your second year onward. - Receive six major paid holidays annually after three months of employment. - Benefit from 5 sick days (40 hours), subject to the provisions of the NYS Paid Sick Leave Act. - Take advantage of license reimbursement after one year of employment. - Health insurance is available, subject to plan eligibility requirements. - Participate in the 401(k) matching program after one year of employment. - Access benefits from Paychex, including Payactiv. - GLHS is recognized as a great place to work, with high employee retention rates (93% retention of employees 2 years+), positive Google reviews, and a strong company culture.