Join our team and help us shape the future of healthcare! We are seeking a highly skilled and motivated Remote Clinical Review Specialist to join our growing team. This is a full-time telecommuting opportunity based in Oklahoma, offering a competitive salary and the chance to make a real difference in people's lives.
Aeetna Remote Jobs (Part Time, Full Time) - Clinical Review Specialist Job Responsibilities:
Reporting to the Director of RN Reviews, you will play a critical role in ensuring the quality and consistency of our clinical reviews. Your responsibilities will include:
- Conducting comprehensive reviews of Utilization Management (UM) processes and clinical notes to ensure adherence to the UM Standard Operating Model.
- Reviewing clinical records for pre-certification, concurrent reviews, and clinical requests to verify the appropriate use of clinical information in decision-making.
- Demonstrating strong clinical judgment, expertise in utilization reviews, and proficiency in applying clinical need standards (e.g., MCG, InterQual).
- Championing the Aeetna Medicaid clinical philosophy and UM Standard Operating Model.
- Applying review guidelines to evaluate consistency with UM programs, policies, and procedures.
- Collaborating with clinical leadership to ensure consistency and accuracy in clinical judgments and alignment with state-specific requirements.
- Evaluating UM capabilities for consistency with NCQA UM principles.
- Completing assigned review expectations in a timely, effective, and accurate manner, adhering to all deadlines.
- Maintaining accurate records of all relevant information in the assigned review tool.
- Identifying opportunities to implement best practice approaches and improvements to enhance outcomes and operational efficiency.
- Contributing to the achievement of unit operational and quality goals.
- Meeting all performance expectations and organizational objectives.
- Demonstrating a high level of accountability.
- Serving as a model change agent and facilitating change initiatives.
- Maintaining consistency with processes and methodologies at the individual level.
- Analyzing data to identify areas for development and implementing interventions to improve the utilization of management review results.
- Utilizing knowledge of oversight care concepts, ideally including Medicaid and Federal healthcare guidelines.
- Distinguishing between standard operating procedures and strategies.
- Meeting deadlines and taking responsibility for achieving optimal, accurate expectations.
- Possessing excellent interpersonal and communication skills (verbal and written).
- Demonstrating the ability to self-direct and thrive in a team environment.
- Proficiency in utilizing RN Review methods and processes.
- Advocating for accessible resources using sound judgment and a collaborative approach to support organizational goals.
- Demonstrating versatility in a fast-paced environment.
- Applying innovative critical thinking skills and a commitment to continuous quality improvement.
Required Qualifications:
- Must reside in Oklahoma.
- Valid Oklahoma driver's license as an Enrolled Attendant by the State Board of Nursing.
- 4+ years of clinical nursing experience.
- 3+ years of utilization review, prior authorization/concurrent review experience.
- 3+ years of experience interpreting and applying national clinical need standards (e.g., MCG, InterQual).
- 2+ years of experience using computers, keyboard navigation, navigating various systems and applications; and utilizing MS Office Suite applications (Teams, Viewpoint, Word, Excel, etc.).
- Willingness and ability to provide on-call UM coverage to evenings and weekends on a rotational schedule as needed by the State regulatory agency.
Preferred Qualifications:
- Experience with oversight care concepts, ideally including Medicaid and additional Federal healthcare insights.
- Up-to-date knowledge of NCQA UM guidelines.
- Schooling: At least Associate's degree or certification nursing degree required; BSN preferred.
About CVS Wellbeing:
We are committed to delivering enhanced, human-driven healthcare for a rapidly changing world. Our core values emphasize diversity, equity, and inclusion. We are an equal opportunity employer and value all individuals regardless of their background.
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Ready to contribute to our mission? Apply now and let's discuss how you can be a valuable member of our team.
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