Clinical Reviewer, RN, LPN, or LCSW

  • Kepro
  • Remote
  • Nov 16, 2021
Registered Nurse, Licensed Practical Nurse, Licensed Clinical Social Worker

Job Description

Clinical Reviewer

  • Are you an experienced Clinical Reviewer looking for a new challenge?
  • Do you value care management and quality improvement?
  • Are you motivated, energetic, and excited to become part of the Kepro team?

If so, you might be our next new team member!

This is a fully remote position.

Candidates – please take note. Kepro holds significant contracts with the federal government. As of December 8, 2021, Kepro will require its employees to be fully vaccinated against COVID-19 as required by Executive Order 14042. New hires must be fully vaccinated as of their start date and provide proof of vaccination during the onboarding process. Medical and religious accommodations are available to those who qualify.

Who we need:

Kepro’s Clinical Reviewer utilizes clinical expertise for the review of medical records against appropriate criteria in conjunction with contract requirements, critical thinking and decision-making skills to determine medical appropriateness.

Why us?

Kepro is a rapidly growing national quality improvement and care management organization. We work to ensure that over 20 million people receive the right care, at the right time, in the right setting.

People Focused. Mission Driven.

Shape the future of healthcare with us. We are mission driven to improve lives through healthcare quality and clinical expertise.

We do this through our people.

At Kepro, you can do meaningful work that makes a real difference for the lives of individuals across the country. We are an organization that cares deeply about our employees and we provide the training and support to do the best work of your career.

Benefits are a key component of your rewards package at Kepro. These benefits are designed to provide you and your family additional protection, security, and support for both your career and your life away from work. They are comprehensive and fit a variety of needs and situations. Our benefits include comprehensive health plans, paid time off, retirement savings, corporate wellness, educational assistance, corporate discounts and more.

What you’ll do:

  • Utilizes clinical expertise for the review of medical records against appropriate criteria in conjunction with contract requirements, critical thinking and decision-making skills to determine medical appropriateness.
  • Performs all applicable review types as workload indicates, accurately and timely. These may include:
  • Audiology, Diagnostic Imaging, DME, inpatient hospital admissions/concurrent review, PT/OT/ST, Home Health/Private Duty Nursing, EPSDT; Children’s Behavioral Health.
  • Determines approval or initiates a referral to the physician consultant and processes physician consultant decisions ensuring reason for the denial is described in sufficient detail on correspondence.
  • Maintains current knowledge base related to review processes and clinical practices related to the review processes.
  • Foster positive and professional relationships with internal and external customers Attends training and scheduled meetings for maintenance and use of current/updated information for review.
  • Maintains medical records confidentiality at all times through proper use of computer passwords, maintenance of secured files, adherence to HIPAA polices.
  • Utilizes proper telephone etiquette and judicious use of other verbal and written communications, following KEPRO policies, procedures and guidelines.
  • Other duties as assigned. The list of accountabilities is not intended to be all-inclusive and may be expanded to include other duties that management may deem necessary.

What you’ll need:

Qualifications

  • Active unrestricted LPN, RN, Licensed Social Worker or other applicable State and/or Compact State clinical license per contract requirements.
  • Graduation from an accredited Diploma, Associates or Bachelor’s Degree Program

Knowledge, Skills, Abilities

  • Knowledge of InterQual or MCG (Milliman) criteria strongly preferred.
  • Knowledge of current NCQA/URAC standards strongly preferred
  • Knowledge of the organization of medical records, medical terminology, and disease process required.
  • Strong clinical assessment and critical thinking skills required. Medical record abstracting skills required.
  • Excellent verbal/written communication skills required.
  • Ability to work in a team environment.
  • Flexibility and strong organizational skills needed.
  • Must be proficient in MS Office and internet/web navigation.

Experience

  • 2+ years of relevant clinical experience
  • Minimum of one year UM/UR and/or Prior Authorization or related clinical experience.
  • Experience with State Medicaid programs strongly preferred.

Thank You!

We know your time is valuable and we thank you in advance for applying for this position. Due to the high volume of applicants we receive, only those who are chosen to advance in our interview process will be contacted. We sincerely appreciate your interest in Kepro and invite you to apply to future openings that may be of interest. Best of luck in your search!

~ The Kepro Talent Acquisition Team

Mental and Physical Requirements

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations will be made as required by law in an attempt to enable an individual with a disability to perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to sit for prolonged periods of time; key and/or control objects; interact extensively with internal and external customers; occasionally lift and/or move objects weighing up to 10 pounds; and occasionally travel within the state.

EOE AA M/F/Vet/Disability

Kepro is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.