Clinical Correspondence Review Nurse Remote in New York

Job Description

Job Summary

The Clinical Correspondence Review Nurse is responsible for performing quality reviews of written clinical determination letters to members and providers to ensure clinical determination letters adheres to prescribed Federal laws, CMS and Medicaid regulatory guidelines or requirements, and NCQA accreditation standards, for assigned Medicare, Medicaid or Marketplace programs.

 

Knowledge/Skills/Abilities

• Conducts quality review of the clinical determination letters generated for members, providers and facilities to ensure regulatory and accreditation standards (as applicable) are met.
• Assist in the development of clinical adverse rationale templates in support of federal health literacy standards, regulatory and accreditation requirements.
• Provide support, guidance and training to non-clinical staff who’s responsible for clinical correspondence and Medical Directors regarding letter program quality, questions and concerns clinical adverse determinations.
• Assist the Medical Directors with inquiries pertaining to adverse rationale changes and updates.
• Identify through quality reviews opportunities for improvement and report training opportunities to management.
• Track and report non-compliance and quality concerns to management and appropriate teams to minimize risks.
• Participate in workgroups and special projects for department as assigned.
• Support external regulatory and internal audits, litigation inquires, state or CMS inquires as required by management.
• Adheres to departmental standards, policies, protocols.
• Maintains detailed records of auditing results.
• Meets minimum production standards.
• Maintains member/provider confidentiality in compliance with the Health Insurance Portability and Accountability Act (HIPAA) and professionalism with all communications.
• Strong Detailed-Orientated
• Organization and time-management skills
• Excellent verbal and written communication skills
• Analytical and problem-solving skills
• Moderate to advanced level skill with Microsoft Office: Word, Excel, Team, Outlook, etc.
• Ability to work independently while supporting team goals
• Ability to work in a fast-paced environment
• Strong interpersonal skills

Job Qualifications

Required Education: Completion of an accredited Registered Nurse (RN) Program

Required Experience:

• Minimum 3 years Managed Care experience
• Minimum 3 years Utilization Management Review experience
• Great communication, organization and interpersonal skills

 Required Licensure or Certification:

Active, unrestricted State Registered Nurse (RN) License in good standing

Preferred Qualifications:

• 5+ years of experience in Utilization Management in Managed Care setting
• 5+ years of clinical correspondence processing and quality review experience

 

 

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.