Clinical Letter Writer (LVN/RN)

Company: TalentBurst, Inc.
Location: Arlington
Posted on: June 24, 2022

Job Description:

Clinical Letter Writer (LVN/RN)

100% Remote

Time zone: Central Time Zone hours between 8:00am-5:00pm Central

Licensed in the Workers Home State

LVN/LPN or RN OK

6 Months+

Requirements: -

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)

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