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Medical Review Clinician

Location: Portland, OR
Job Code: 287
# of Openings: 1

Description

 

Utilization/Appeals Review Nurse   

Are you seeking a career growth opportunity with a national leader which is driven by mission to improve the quality and integrity of healthcare?

AllMed Healthcare Management provides medical review solutions to leading health insurance carriers, medical management organizations, TPAs, PBMs and hospital groups nationwide. Our medical review solutions power clinical decision-making processes for hundreds of clients which provide benefits to over 200 million Americans, and through steady growth AllMed is a recognized leader in this dynamic market. 

We are currently seeking experienced Utilization/Appeals Review Nurses to join our clinical operations team, working onsite in our beautiful office in downtown Portland, Oregon.

In this role, you will work closely with our medical directors and national peer physician specialist panel to provide written medical chart reviews and determinations, which power pre-authorizations and appeals for medical treatments and procedures in over 80 specialties and sub-specialties of medicine.

 

POSITION DESCRIPTION

The Utilization/Appeals Review Nurse is responsible for:

  • Reviewing medical records and preparing case summaries for physician review of prior authorizations and appeal determinations that align with health plan policies and clinical review criteria
  • Ensuring the accuracy of determinations by validating information in the medical record against health plan policies and clinical review criteria
  • Ensuring the quality of final written reviews by close attention to grammar, punctuation, spelling,  formatting, and accuracy
  • Meeting quality and productivity standards
  • Working to continuously improve the quality and efficiency of our operations through individual and team projects, participation in continuous improvement events and ongoing learning

REQUIRED SKILLS

  • Current unrestricted Registered Nurse (RN) license
  • Combination of LPN/LVN and utilization review experience may substitute for RN
  • Minimum one year acute care nursing experience
  • Ability to type minimum 35 words per minute
  • Excellent writing and documentation skills and customer service
  • Computer literacy with demonstrated proficiency in Microsoft Office, email, database and contact management software, and browser-based workflow applications
  • Exhibit a high degree of professionalism in written and verbal communications
  • Attention to detail; critical eye to catch mistakes and errors

Preferred Experience/Skills

  • Experience in a fast-paced, production-oriented setting
  • Demonstrated experience in utilization management, case review and/or medical necessity review/appeals in a payer or provider setting
  • Bachelor of Nursing or degree in equivalent field of study

 

BENEFITS

AllMed offers generous compensation and our competitive benefits program includes comprehensive medical and dental care, matching 401K, paid time off, flexible spending accounts, disability coverage, and other benefits that help provide financial protection.

 

AllMed provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, AllMed complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities.





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(800) 400-9916
111 SW Fifth Ave., Suite 1400, Portland, OR 97204
AllMed Healthcare Management, Inc. All rights reserved.

AllMed is an independent review organization with a panel of 400 physician peer reviewers who are licensed, board-certified and in active practice, covering more than 80 ABMS specialties and sub-specialties. AllMed offers medical, copy-editing and customer resources that enable clients to improve quality of care and patient safety.