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 payer 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.
• Responsible for additional duties as directed by the department’s management.

Basic Qualifications

• College degree in healthcare, nursing, or related field.
• 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.
• 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.

Preferred Qualifications

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