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Clinical Nurse Reviewer

Integrated Prescription Management
3.0 out of 5
Remote
$65,000 - $95,000 a year - Full-time

Location

Remote

Benefits
Pulled from the full job description

  • 401(k)
  • 401(k) matching
  • Dental insurance
  • Employee assistance program
  • Flexible spending account
  • Health insurance
  • Life insurance

Full job description

Job Summary:
We are seeking a dedicated Clinical Nurse Reviewer to join our team. This position is responsible for supporting clinical operations and clinical programming provided to IPM members, including member care, clinical program support, and support of quality assurance initiatives.

Job can be done from Fresno or remote, with travel to the Fresno office at least annually.

Primary Duties

  • Review prior authorization requests consistent with adopted clinical criteria as part of the clinical services team.
  • Coordinate prior authorizations and appeals outsourced to independent review organizations (IRO).
  • Conduct peer-to-peer discussions with health care providers as requested.
  • Perform outreach to health care providers to help guide appropriate prescribing consistent with optimal patient outcomes in alignment with a plan’s benefit design.
  • Perform outreach to members to answer questions about plan design and formulary options.
  • Provide education to internal staff and external stakeholders.
  • Aid in the development and maintenance of member facing clinical materials.
  • Participate as a member of the Utilization Management Committee.
  • Support the development and operation of clinical programs to enhance member experience and guide optimal clinical outcomes.
  • Perform scientific literature evaluation using multiple drug resources to support clinical decisions.
  • Work cooperatively with clinical pharmacist and medical reviewers to provide consistent prior authorization request reviews.
  • Present medical and clinical information to clients, brokers, or TPAs as requested.
  • Support analysis and interpretation of claims data and available clinical information to identify opportunities to enhance clinical program offerings and performance.

Skills
To be successful, this position requires:

  • Sound clinical judgment through the application of clinical criteria in prior authorization and case reviews.
  • Effective oral and written communication skills, including with members and healthcare providers.
  • Strong interpersonal skills.
  • Self-motivation and the capability to work independently and with minimal oversight.
  • Collaborative planning and coordination skills.

Education and Experience

  • Current unrestricted nursing license, RN, in California and state of residence; BSN preferred
  • Certified Diabetes Educator (CDE) preferred
  • Clinical informatics experience preferred
  • 7 years of patient treatment experience
  • 2 years of prior authorization or medical case review experience

Benefits

We offer competitive compensation and benefits for eligible employees, including:

  • Medical, dental, and vision benefits
  • Life insurance
  • FSA plan
  • 401(k) plan with matching contributions
  • Paid time off and additional paid holidays

Job Type: Full-time

Pay: $65,000.00 - $95,000.00 per year

Benefits:

  • 401(k)
  • 401(k) matching
  • Dental insurance
  • Employee assistance program
  • Flexible spending account
  • Health insurance
  • Life insurance
  • Paid time off
  • Professional development assistance
  • Referral program
  • Tuition reimbursement
  • Vision insurance

Medical specialties:

  • Endocrinology
  • Internal Medicine

Standard shift:

  • Day shift

Supplemental pay types:

  • Bonus opportunities

Supplemental schedule:

  • On call

Weekly schedule:

  • Monday to Friday
  • Weekends as needed

Work Location: Remote