Clinical Reviewer (BHJOB1435_34899)

Delivering smart solutions with an eye on People, Process, and Technology Our team is comprised of individuals rich with recruiting experience, technology knowledge, and customer service. Dedicated to their community, clients and associates, these individuals have a common mantra: “We will make it happen, deliver on our promises and manage every detail along the way.” Our internal slogan of P.R.I.D.E. (Putting Remarkable Into Daily Efforts) is our driving focus. Our skilled associates, led by this team of professionals, enable organizations to achieve their business and personnel needs both quickly and cost effectively.

We are partnering with a healthcare organization seeking experienced Nurse Reviewers for a long-term engagement with the possibility of full-time conversion. This role focuses on conducting medical record reviews across multiple service categories while ensuring compliance, medical necessity, and accuracy. Top 5 Ways You’ll Make an Impact Conduct medical record reviews using InterQual, MCG, or similar criteria to determine medical necessity. Perform utilization management across DME, acute care, inpatient services, imaging, genetic testing, and outpatient reviews. Use clinical judgment and regulatory knowledge to assess documentation against guidelines and contract requirements. Communicate with providers and internal teams to gather information, resolve questions, and support the review process. Meet productivity, turnaround times, and quality standards while managing daily workload and multiple review types. Job Summary: As a Nurse Reviewer, you will evaluate clinical documentation to ensure services meet criteria and regulatory standards. You will conduct utilization reviews across diverse service categories, using critical thinking and established guidelines to make informed determinations. This role supports high-quality, compliant review processes and requires the ability to manage volume, maintain accuracy, and communicate effectively with providers and colleagues.

Complete assigned review types accurately and within required timeframes. Analyze daily caseloads and adjust workflow as needed to meet department demands. Support quality assurance by participating in monitoring activities and addressing documentation or process concerns. Maintain current knowledge of review guidelines, clinical practices, and applicable criteria tools. Serve as a resource for review-related questions and support consistent application of guidelines. Act as a liaison to providers for documentation needs, clarification, and issue resolution. Foster professional communication with internal and external stakeholders to support smooth review operations. Participate in scheduled training sessions and updates related to review criteria and workflow processes. Crosstrain on additional review categories to support staffing flexibility. Adhere to all HIPAA, privacy, and security standards.