Certainly. Here's a more polished and professional version of the job description for a Clinical Reviewer (RN) role:
Job Title: Clinical Reviewer (RN)
Reports To: Director / Assistant Director
Position Summary:
The Clinical Reviewer (RN) is responsible for conducting comprehensive clinical reviews related to State and Federal Independent Dispute Resolution (IDR) cases. This role includes evaluating prior authorization and disputed benefits, supporting Medical Review Analysts and Physician Consultants to ensure accurate, timely, and compliant determinations.
Key Responsibilities:
- Perform in-depth clinical reviews for prior authorization and appeal cases, including medical chart screening, research of applicable regulatory and payer requirements, completion of electronic documentation, and preparation of final determinations
- Serve as a clinical resource for both administrative and clinical teams, providing guidance, technical support, and clarification of determinations
- Participate in staff training sessions and huddles; provide mentorship and onboarding support for new RN reviewers
- Assess and adjudicate claims in accordance with current guidelines and protocols
- Collaborate with cross-functional teams to ensure quality, consistency, and compliance
- Participate in ongoing training and professional development
- Perform additional duties as assigned to support departmental goals
Qualifications:
- Active Registered Nurse (RN) license (Required)
- Bachelor's degree in Nursing or graduation from an accredited RN program (Required)
- Minimum of two (2) years of clinical experience in a healthcare setting (Required)
- Proficiency in electronic medical records (EMR) systems
- Strong analytical and problem-solving skills
- Excellent written and verbal communication abilities
- Ability to work independently with minimal supervision
- Flexible, detail-oriented, and capable of adapting in a fast-paced, time-sensitive environment