Job Description

TITLE: Clinical Reviewer (RN) AIMS & IDR, NY Medicaid

LOCATION: Remote (must live in New York, do not apply if outside of NY)

REQUIRED EDUCATION/EXPERIENCE:

• At least 2 years of acute/med surg experience
• BSN required
• Unrestricted NYS RN license
• Strong computer/technology skills

GENERAL RESPONSIBILITIES:

These candidates will be cross trained to work with the IDR team and the AIMS Clinical Review team. The AIMS team deals with NY Medicaid.

This individual will complete the full spectrum of activities related to State and Federal Independent Dispute Resolution (IDR) case determinations. They will conduct clinical level review, Prior Authorization, and disputed benefits review, supporting Medical Review Analysts, and Physician Consultants to ensure an appropriate and accurate process.

DUTIES:

1. Conduct reviews up to and including the appeal level. This includes chart screen, compiling regulatory guidance, researching insurer requirements, complete electronic worksheets and preparing final determinations.
2. Act as a resource for the administrative and clinical staff in training, problem solving, and clarifying determinations. Will provide technical assistance and conduct/participate in staff huddles.
3. Training and mentoring new RNs as the project expands.
4. Claims assessment and adjudication.
5. Participate in collaborative training.
6. Other activities as may be deemed necessary.

QUALIFICATIONS:

1. Knowledge and experience with electronic medical records.
2. Ability to oversee, problem solve, and work collaboratively with peers, medical, analytical, and administrative support staff.
3. Excellent written and verbal skills.
4. Ability to work independently with little supervision.
5. Ability and desire to be flexible, innovative, and creative.

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