Telephonic Registered Nurse Clinical Reviewer - EviCore

Telephonic Nurse Clinical Reviewer -EviCore-Remote

Full time RN Role- Remote

Monday- Friday 12:30pm-9:00 pm EST (Required Shift)

Start Date: Monday, September 14th

Shift for this role is Monday- Friday 12:30pm-9:00 pm EST. Start time may vary based on your local time zone. The first 7 weeks of employment will be day shift for training purposes. In the future, shift may vary based on business need to any 8 hour shift between the hours of 7am in your local time zone – 10 pm EST, Monday – Friday. There are no scheduled absences allowed during training for this role.

The Clinical Reviewer will be responsible for:

• All clinical certification activities, which include but are not limited to evaluating telephone, fax or WEB requests for authorization of clinical services from physician offices/and or imaging centers, comparing requests against established clinical protocols and authorizing services or referring requests for expert clinical review as appropriate.

• Know and understand complex case specialties and case reviews.

• Review clinical information submitted by providers to appropriate criteria and standards and makes decision to issue a review determination or to refer to physician review if criteria are not met. 

• Maintain current departmental standards related to productivity. 

• Train in clinical certification, utilization management, URAC and NCQA principles, policies, and procedures. 

• Prepare program correspondence as needed. 

• Serve as a resource for members calling for assistance.

• Make outbound calls as required. 

• Refer provider and member complaints, and appeals to appropriate departments. 

• Maintain patient confidentiality in accordance with EviCore standards established in compliance with HIPAA and State regulations. 

• Provide outstanding customer service ensuring callers receive the highest possible service. 

• Run and analyze reports to ensure all tasks are completed in a timely fashion and meet regulatory requirements.

• Assist team members in departmental chats, by phone and in person. 

• Act as training assistant when assigned. 

• Assist team members with questions, participates in team meetings. Can be assigned to projects to support the department as needed. 

• Performs related duties as required. 

Essential Functions:

• Must be able to sit through shift, demonstrate advanced proficiency in MS Office applications. 

• Excellent communication skills both verbal and written;

• Excellent problem solving and customer service skills are required. 

• Must be self-directed and highly motivated with an ability to multi-task.