• Job Description

  Req#: CLINI004796

  * Position is eligible for Remote / Work from Home opportunity *

  Department: Part B Appeals

  Telecommuting Eligible: Yes

  Job Grade: E11

  Notice of Collection & Privacy Policy for Applicants Residing in California: California Applicant Privacy Policy | Noridian (noridiansolutions.com)

  Job Title

  Clinical Reviewer (RN)

  Job Summary

  The Clinical Reviewer (RN) evaluates medical records applying clinical expertise to determine compliance with applicable guidelines and standards of care. This position documents decisions and rationale and communicates results with stakeholders through various means providing education and guidance.

  Essential Functions

  Key Duties/Responsibilities/Accountabilities

  • Reviews, research, and analyzes medical records and other documentation to determine compliance with regulations, guidelines, and standards of care.
  • Applies accurate, independent coverage and payment decisions using consistent evaluation standards.
  • Communicates decisions and provides associated education to stakeholders using various methods.
  • Determines recommendations for actions based on analysis of review results.
  • Prioritizes workload depending on business need and direction.
  • Identifies and communicates potential fraud, waste, and abuse using established work instructions.
  • Collaborates and communicates with peers and leaders.
  • Participates in team quality and calibration review processes.
  • Serves as a mentor to peers.
  • May prepare documents for, and participate in, legal hearings.

  Non-Essential Duties and Functions

  • Assists with special projects as assigned.

  Minimum Qualifications

  • Current, active, unrestricted RN license in state of practice
  • 2 years' clinical experience
  • 1 year Microsoft Office experience
  • Strong verbal and written communication skills
  • Strong computer experience

  Preferred Qualifications

  Above requirements and the following:

  • Bachelor's degree in Nursing (BSN, BAN, etc.)
  • 1 year experience evaluating medical records applying clinical expertise to determine compliance with applicable guidelines and standards of care
  • 1 year experience utilization review or case management
  • 1 year experience educating external customers
  • 1 year experience leading projects, initiatives, or processes
  • Strong prioritization, problem solving, and organizational skills
  • Strong attention to detail
  • Knowledge of coding
  • Microsoft proficiency
  • Strong business writing experience

  Environment and Cognitive/Physical Demands

  • Office Environment
  • Ability to read, hear, speak, keyboard, reason, communicate effectively and problem solve
  • Requires prolonged sitting and telephone use
  • Requires the use of office equipment such as computer terminals, telephones, copiers and printers
  • Infrequent lifting to 15 pounds
  • Infrequent stooping

  Segregation of Duties

  Every employee is responsible to perform their duties and responsibilities in accordance with Noridian values, policies and procedures, including but not limited to: Segregation of Duties Principles, HIPAA, Security and Privacy, CMS requirements, the Noridian Compliance Program and any other applicable laws, rules and regulations.

  Statement of Other Duties

  This document describes the essential functions, requirements, and responsibilities of this job, and is not intended to be a complete list of all tasks and functions. Employees may be requested to perform job related tasks other than those specifically listed in this description and may be required to perform any task requested by the supervisor or management.

  Total Rewards Package:

  Health, Dental and Vision Insurance, Voluntary Insurance Plans, Health Savings and Flexible Spending Accounts, 401k and Company Match, Company-paid Life Insurance, Education Assistance Program, Paid Sick Leave, Paid Holidays, Increasing PTO Accrual Plan, Medical/Parental/Disability Leave, Workers Compensation, Retiree Benefits, Severance Package, Employee Assistance Program, Financial and Health Wellness Benefits, Casual Dress, Open Office Setting, and Online Learning System.

  CMS Access Compliance and Regulation Contingency Statement

  Some positions require compliance with (i) federal and agency specific regulations and related clauses included in Noridian's prime contracts with the Government, (ii) background checks, and (iii) eligibility for a government-issued identification card.

  An employee in this position may be required to possess a “Federal Identification Card” (Federal ID) as a condition of employment. Federal ID’s may include one of the following: Personal Identity Verification (PIV) card, Personal Identity Verification-Interoperable (PIV-I) card, a Local-Based Physical Access Card issued by CMS, or a Local-Based Physical Access Card issued by another Federal agency and approved by CMS. Obtaining a Federal ID and continued eligibility for this position may require the successful completion of a Federal Background Investigation performed by the Federal Government and a residency requirement that you have lived in the United States at least three out of the last five years. Failure to obtain a Federal ID may result in the removal from the position or termination of employment.

  Equal Employment Opportunity

  Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities as well as Sexual Orientation or Gender Identity.

  Below is the salary range for potential new hires.

  Salary Range: $52,120.20 – $85,724.33

  Other Compensation: Incentive Plan

  Lifestyle Benefit: $50/month

  This job will be closed 09/18/2024 at 8:00AM CST. No further applications will be considered.

  Qualifications

  Licenses & Certifications

  Required

  Registered Nurse

  Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

  The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)

• About the company

  Noridian delivers the most dependable program administration to Center for Medicare & Medicaid Services, State Medicaid and Veterans Administration.

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