Clinical Nurse Reviewer

The Clinical Nurse Reviewer plays a crucial role in Comfort Medical by evaluating and assessing medical records, progress notes, and healthcare Certificates of Medical Necessity (also known as CMN’s or Prescriptions) to ensure compliance with industry standards, federal and state regulations, and quality of care. This position requires a strong understanding of medical terminology, healthcare protocols, and attention to detail to maintain the highest standards of patient care and safety.

Major Areas of Accountability

• Review and analyze patient medical records, ensuring accuracy, completeness, and compliance with relevant regulations and guidelines.
• Collaborate with healthcare professionals, including physicians, nurses and appropriate staff, to ensure receipt of proper documentation.
• Responsible for understanding and adhering to all Medicare Local and National Coverage Determinations (LCD’s and NCD’s), policy articles, government rules and regulations, and contracted payor policies pertaining to services and products provided.
• Will work closely with the department Manager and external resources to accurately interpret and explain policy documentation requirements to all company stakeholders.
• Responsible for navigating between multiple computer-based systems to accurately review audits/appeals as assigned
• Will identify and communicate deficiencies/discrepancies in documentation while complying with company policies & procedures.
• Ensure audit/appeal packets are assembled and submitted correctly according to department policies and procedures within the defined timeframe.
• Effectively communicates with Comfort Medical internal stakeholders clinical need qualifications and regulatory requirements.
• Serve as a clinical resource for non-medical staff.
• Support training and education on clinical need qualifications, justification, and regulatory requirements when knowledge gaps are identified for internal associates.
• Participate in peer review processes to assess the quality of care provided by other clinicians, offering constructive feedback and recommendations for improvement.
• Analyze and provide feedback to Comfort Medical stakeholders with respect to trends in clinical patient care and identify opportunities for quality improvement.
• Responsible for keeping Manager informed of deficient audits/appeals, patterns, errors, or other systematic problems identified.
• Responsible for understanding and adhering to all company and department policies, procedures, and process documents.
• Comfort Medical employees are required to conduct business to the highest ethical and professional standards; comply with applicable laws and regulations, the MedTech Code of Conduct, and company policies.
• Responsible for additional duties assigned by the department’s management.

Basic Qualifications

• College Degree in healthcare, nursing, or related fields.
• Minimum of 2 years’ experience working as a clinical nurse reviewer or in utilization management.
• Must have active LPN or RN Certification in the state in which they reside (must maintain certification).
• Ability to work collaboratively and independently and stay on task.
• Strong background knowledge in healthcare regulatory, government policy, and contracted payer policy.
• Excellent medical terminology skills.
• Excellent written and verbal communication skills.

Preferred Qualifications

• 5+ years’ DME industry experience (urological/ostomy)
• EHR system experience
• Certified Professional in Healthcare Quality (CPHQ)

At Coloplast, we believe in recognizing and rewarding the contributions of our employees. Our total rewards package is designed to support your well-being, foster your professional growth, and ensure a healthy work-life balance. Here is some of what you can expect:

• Health and Wellness: Comprehensive medical, dental, and vision insurance plans to keep you and your family healthy. Plus, access to company sponsored wellness programs and mental health resources, paid leave of absence for qualifying events and generous paid parental leave for both birthing and non-birthing parents.
• Financial Security: A competitive 401(k) plan with company match that vest immediately, financial planning services to help you secure your future, and corporate discount programs for goods and services.
• Work-Life Balance: Generous paid time off, flexible work hours, and flexible work arrangement options to help you balance your personal and professional life may be available.
• Professional Development: Opportunities for continuous learning and career advancement through training programs, mentorship, and tuition reimbursement.
• Recognition and Rewards: Recognition programs to celebrate achievements and contributions, including peer recognition, bonuses, awards, and special events.
• Community and Culture: A supportive work environment where everyone feels valued and has a sense of belonging.  Participate in team-building activities, volunteer opportunities, and company-sponsored events. Sustainability strategy that outlines our ambitions for how to run our company in a more sustainable way.
• •              Competitive Compensation:  The compensation range for this position is $80,740 - $100,000. Actual compensation is influenced by a variety of factors including but not limited to skills, experience, qualifications, and geographic location. Hired candidates may be eligible to receive additional compensation in the form of bonuses and/or incentives.

Comfort Medical provides an extensive selection of name brand catheter and ostomy supplies to thousands of customers nationwide. Our attention to detail, unmatched customer service, and dedication to helping our customers live happier, healthier lives are just a few of the many reasons we are one of the fastest growing catheter and ostomy supply companies in the nation!​

Comfort Medical employees are required to conduct business to the highest ethical and professional standards; comply with applicable laws and regulations, the Advamed Code of Ethics on Interactions with Healthcare Professionals, and company policies.

Comfort Medical is committed to a policy of Equal Employment Opportunity (EEO) which means we employ and promote individuals based on their merits, regardless of race, color, religion, sex, national origin, age, disability, veteran status, pregnancy, sexual orientation, gender identity or expression, genetic information, marital status, citizenship status, status with regards to public assistance or any other protected classification.

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