Job Description

IPRO is currently seeking a Clinical Reviewer to work with IPRO’s affiliate, Lumetra.  The incumbent will be responsible for the review and processing of requests for independent reviews from external agencies and the maintenance and data quality of the clinical services department in accordance with contract reporting requirements.

This position will be an office-based position working in Lake Success, NY with the possibility of occasional remote work. 

Work hours 10AM EST - 6PM EST (7AM PST - 3PM PST)

 Essential Duties and Responsibilities

• Perform case review utilizing criteria and clinical knowledge for medical necessity and quality of care issues.
• Formulate a case summary and the review questions for the Physician Reviewer based upon the External Agency’s concern(s).
• Review physician determinations, ensuring all categories of concern have been addressed. 
• Prepare written correspondences to contractors, providers and beneficiaries/representatives. 
• Maintain contractual timeframes and URAC standards for case completion. 
• Interface with the Medical and Clinical Director and other departmental team members.
• Perform and coordinate other departmental activities and reports as needed. 

Qualifications:

• The ability to communicate effectively and interact with providers, internal customers and beneficiaries /representatives.
• Excellent communication skills and professional demeanor
• The ability to work independently, as well as in a team environment.
• Proficient in the use of standard EHR applications, office technology and Microsoft applications including Word, Excel, and PowerPoint.
• Proficient with analytical tools and knowledge of data analysis methodology
• Ability to handle sensitive and confidential information.
• Affinity for delivering the highest level of customer service

Education & Experience:

• Licensed Registered Nurse and a graduate of an approved registered professional nurse’s training program, required
• Bachelor of Science in Nursing (BSN) required
• Three (3) years clinical experience in an acute care setting or related experience, required.
• Experience in utilization and quality reviews, required
• Experience in Data Analytics, preferred
• Experience in the application of InterQual criteria, preferred.
• Experience in managed care, quality management and peer review, preferred.

The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. The annualized salary range for this position is $70,000.00 – $90,000.00.  Actual salary range and/or hourly rate depends on a variety of factors including experience, education, credentials, location, and budget.

The salary range and/or hourly rate listed does not include other forms of compensation or benefits.

IPRO is an Affirmative Action/Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity or expresssion, disability, protected veteran status or military status. 

Job Tags

Hourly pay, Full time, Contract work, Temporary work, For contractors, Remote job,

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