Description The Clinical Nurse Reviewer plays a crucial role in the healthcare industry by evaluating medical records, treatment plans, and healthcare procedures to ensure compliance with industry standards and regulations and uphold quality of care. This position requires a strong understanding of medical terminology, healthcare protocols, and attention to detail to maintain the highest standards of patient care and safety. Requirements Review and analyze patient medical records, ensuring accuracy, completeness, and compliance with relevant regulations and guidelines. Assess the quality and appropriateness of medical care provided, identifying areas for improvement and adherence to best practices. Ensure that healthcare providers maintain proper documentation, including diagnosis, treatment plans, and progress notes, following established protocols. Stay updated on healthcare regulations, policies, and guidelines, and ensure that healthcare practices align with these requirements. Assess medical necessity and appropriateness of procedures, treatments, and services. Conduct peer reviews to ensure quality and regulatory compliance. Provide recommendations for coverage determinations and appeals. Document findings and decisions in patient management systems. Stay current with clinical guidelines (e.g., InterQual, Milliman, CMS) and healthcare regulations. Qualifications Active RN license (state-specific). Bachelor of Science in Nursing (BSN) preferred. Minimum 2–3 years of clinical experience, ideally in case management, utilization review, or quality assurance. Familiarity with healthcare coding standards (ICD, CPT) and insurance protocols. Proficiency in medical terminology, healthcare regulations (e.g., HIPAA), and quality assurance processes. Strong attention to detail to review and assess medical records accurately and identify any discrepancies or issues. Proficiency in Microsoft Office and electronic health record (EHR) systems. Strong analytical, communication, and decision-making skills. Additional Requirements Experience with InterQual or Milliman Care Guidelines. Knowledge of URAC, NCQA, and CMS accreditation standards. Ability to interpret complex medical data and translate it into actionable insights. Detail-oriented with a commitment to accuracy and confidentiality. Work Environment/Physical Demands The work environment and physical demands described here are representative of those that an employee must meet to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. This is a remote position. While performing the duties of this job, the employee regularly works in a climate-controlled environment. Candidates must be able to sit, read, work on a computer, and watch a computer screen for extended periods. Occasionally required to stand, walk, use hands and fingers, kneel, or crouch. Equal Employment Opportunity Commence is an equal employment opportunity employer. All personnel processes are merit-based and applied without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic origin, military and veteran status or any other characteristic protected by applicable law. Commence is committed to providing equal employment opportunities to all applicants, including individuals with disabilities. If you require a reasonable accommodation to participate in the application process due to a disability, please contact Human Resources at (757) 306-4920 or hr@commence.ai. #J-18808-Ljbffr
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