Clinical Review Nurse - Remote

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CLINICAL REVIEW NURSE - REMOTE
ARC Group has multiple positions open for Clinical Review Nurses! These positions are 100% remote. These are direct hire FTE positions with salary, benefits, etc. This is a fantastic opportunity to join a dynamic and well-respected organization offering tremendous career growth potential.

At ARC Group, we are committed to fostering a diverse and inclusive workplace where everyone feels valued and respected. We believe that diverse perspectives lead to better innovation and problem-solving. As an organization, we embrace diversity in all its forms and encourage individuals from underrepresented groups to apply.

100% REMOTE!

Candidates must currently have PERMANENT US work authorization. Sorry, but we are not considering any candidates from outside companies for this position (no C2C, 3rd party / brokering).

SUMMARY STATEMENT
The Clinical Review Nurse is responsible for reviewing and making medical determinations as to the validity of health claims and levels of payment in meeting national and local policies as well as accepted medical standards of care. The incumbent applies clinical knowledge to assess the medical necessity, level of services and appropriateness of care which may include cases requiring prior authorization, complex pre-payment medical review or post-payment medical review.

ESSENTIAL DUTIES & RESPONSIBILITIES
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This list of essential job functions is not exhaustive and may be supplemented as necessary.

90% of time will be spent on one or more of the following activities depending on assignments:

Review and analyze pre and post pay complex health care claims from a medical perspective, inclusive of prior authorization:
  • Perform clinical review work as assigned; may provide guidance to other team members and accurately interpret and apply broad CMS guidelines to specific and highly variable situations.
  • Conduct review of claim data and medical records to make clinical decisions on the coverage, medical necessity, utilization and appropriateness of care per national and local policies, as well as accepted medical standards of care.
  • Review provider practices and identify issues of concern, overpayment and need for corrective action as necessary; includes surfacing potential fraud and abuse or practice concerns.
  • May develop recommendations for further corrective action based on medical review findings.
  • May refer for review, or implement, corrective action related to medical review activities.
  • May process claims and complete project work in the appropriate computer system(s).

The remaining 10% of time will be spent on the following activities depending on assignments:

Identify providers needing education and individually educate providers who are subject to medical
review processes:
  • Initiate or participate in provider teaching activities, creating written teaching material, providing one on one education or education to a group as a result of a medical review (e.g., probe, progressive corrective action, consent, etc.) or appeal.
  • This may involve discussion with CMS leaders and leaders in the provider community.
  • Participate in special projects as assigned.

REQUIRED QUALIFICATIONS
* Valid nursing degree
* 2 years' clinical experience
* Excellent written and oral communication skills
* Demonstrated experience with evaluating medical and health care delivery issues (e.g., Inpatient Rehab Facility)
* Strong computer skills to include Microsoft Office proficiency
* Valid unrestricted Registered Nurse (RN) license

PREFERRED QUALIFICATIONS
* Inpatient Rehabilitation Facility Experience
* Bachelor of Science in Nursing (BSN)
* Insurance industry experience
* Certified Coder

ARC Group is a Forbes-ranked a top 20 recruiting and executive search firm working with clients nationwide to recruit the highest quality technical resources. We have achieved this by understanding both our candidate's and client's needs and goals and serving both with integrity and a shared desire to succeed.

At ARC Group, we are committed to providing equal employment opportunities and fostering an inclusive work environment. We encourage applications from all qualified individuals regardless of race, ethnicity, religion, gender identity, sexual orientation, age, disability, or any other protected status. If you require accommodations during the recruitment process, please let us know.

Position is offered with no fee to candidate.
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Common Interview Questions And Answers

1. HOW DO YOU PLAN YOUR DAY?

This is what this question poses: When do you focus and start working seriously? What are the hours you work optimally? Are you a night owl? A morning bird? Remote teams can be made up of people working on different shifts and around the world, so you won't necessarily be stuck in the 9-5 schedule if it's not for you...

2. HOW DO YOU USE THE DIFFERENT COMMUNICATION TOOLS IN DIFFERENT SITUATIONS?

When you're working on a remote team, there's no way to chat in the hallway between meetings or catch up on the latest project during an office carpool. Therefore, virtual communication will be absolutely essential to get your work done...

3. WHAT IS "WORKING REMOTE" REALLY FOR YOU?

Many people want to work remotely because of the flexibility it allows. You can work anywhere and at any time of the day...

4. WHAT DO YOU NEED IN YOUR PHYSICAL WORKSPACE TO SUCCEED IN YOUR WORK?

With this question, companies are looking to see what equipment they may need to provide you with and to verify how aware you are of what remote working could mean for you physically and logistically...

5. HOW DO YOU PROCESS INFORMATION?

Several years ago, I was working in a team to plan a big event. My supervisor made us all work as a team before the big day. One of our activities has been to find out how each of us processes information...

6. HOW DO YOU MANAGE THE CALENDAR AND THE PROGRAM? WHICH APPLICATIONS / SYSTEM DO YOU USE?

Or you may receive even more specific questions, such as: What's on your calendar? Do you plan blocks of time to do certain types of work? Do you have an open calendar that everyone can see?...

7. HOW DO YOU ORGANIZE FILES, LINKS, AND TABS ON YOUR COMPUTER?

Just like your schedule, how you track files and other information is very important. After all, everything is digital!...

8. HOW TO PRIORITIZE WORK?

The day I watched Marie Forleo's film separating the important from the urgent, my life changed. Not all remote jobs start fast, but most of them are...

9. HOW DO YOU PREPARE FOR A MEETING AND PREPARE A MEETING? WHAT DO YOU SEE HAPPENING DURING THE MEETING?

Just as communication is essential when working remotely, so is organization. Because you won't have those opportunities in the elevator or a casual conversation in the lunchroom, you should take advantage of the little time you have in a video or phone conference...

10. HOW DO YOU USE TECHNOLOGY ON A DAILY BASIS, IN YOUR WORK AND FOR YOUR PLEASURE?

This is a great question because it shows your comfort level with technology, which is very important for a remote worker because you will be working with technology over time...