Clinical Letter Writer (LVN/RN)

  • Lake Houston, TX

Description

100% Remote
Time zone: Central Time Zone hours between 8:00am-5:00pm Central
Must have license in state where you reside – LVN/LPN or RN OK

Experience in UM preferred. (Utilization Management)
IQ or MCG Experience
Letter Writing preferred.
Experience with Microsoft Office/Teams/Excel

The Nurse Reviewer – Clinical Letter Writer (RN or LVN – any state) is responsible for reviewing adverse determination
decisions against criteria and policy, escalating questions to the physician reviewer, and creating
letters that meet regulatory and Plain Language requirements. This position requires a person who
can synthesize various clinical and administrative requirements, communicate well with the team
and clients and write clearly.

Responsibilities

Reviews adverse determinations against criteria and medical policies.
Works with the physician reviewer to monitor the adverse determination process and ensure
notification timeframes are met.
Creates adverse determination notifications that meet all accreditation, State, and Federal
criteria.
Uses Plain Language and good written skills to clearly communicate adverse decisions to both
members and providers.
Works with internal and external staff to ensure that decisions are made, documented and
communicated clearly.
Appropriately identifies and refers quality issues to the Senior Director of Medical Management
or Medical Director.
Appropriately identifies potential cases for Care Management programs.
Communicates appropriate information to other staff members as necessary/required.
Participates in continuing education initiatives.
Collaborates with Claims, Quality Management and Provider Relations Departments as
requested.
Performs other duties as assigned.

Qualifications

Licensed registered nurse (current and unrestricted).
Minimum of three years of direct clinical patient care.
Minimum of one year of experience with medical management activities in a managed care
environment.
Excellent written skills.
Knowledge of managed care principles, HMO and Risk Contracting arrangements.
Experience with clinical decision-making criteria sets (i.e. Milliman, InterQual).

To apply for this job email your details to hr@infiniasearch.com