Nurse - Clinical Review
New
United States, CSTFull-TimeJunior
Salary not disclosed
Apply NowOpens the employer's application page
Job Details
- Experience
- Minimum of two (2) years experience in utilization review, case management, or clinical quality improvement
- Required Skills
- Microsoft ExcelMicrosoft OfficeOrganizational skillsTime ManagementWritten communicationCritical thinkingVerbal communicationPowerPoint
Requirements
- RN, LPN/LVN graduate from an accredited school of nursing
- Current, active unrestricted RN, LPN/LVN license in the state or territory of the U.S.
- Minimum of two (2) years experience in utilization review, case management, or clinical quality improvement
- Proficient technical skills in Microsoft Office (Word, Excel, and PowerPoint) and ability to adapt to new healthcare specific software and systems, required
- Experience working with state and federal regulatory and compliance standards, preferred
- Working knowledge of National Coverage Determination (NCD) and Local Coverage Determination (LCD)
- Knowledge of insurance terminology
- Good organizational and time management skills
- Excellent written and verbal communication skills
- Ability to utilize critical thinking skills
- Highly motivated, self-starter who can work efficiently and independently, or as a team member
Responsibilities
- Performs utilization review of cases to determine if the request meets medical necessity criteria in accordance with medical policies agreed upon with the Client and any applicable governing body.
- Facilitates resolution of escalated cases that may require special handling.
- Performs clinical reviews according to the policies and procedures of HealthHelp within the identified State and Federal or Client agreed upon timeframes.
- Collaborates with client personnel to resolve customer concerns.
- Appropriately identifies and refers quality issues to UM Leadership.
- Assists Physician Reviewers and Medical Directors, as necessary, to ensure compliance with review timeframes.
- Maintains written documentation according to HealthHelp’s documentation policy.
- Ensures consistency in implementation of policy, procedure, and regulatory requirements in collaboration with Nursing Management.
- Engages in phone conversations with ordering providers, members, internal staff, primary care physicians (PCPs), and rendering providers as necessary to facilitate the clinical review process and ensure appropriate care decisions.
- Effectively utilizes various computer systems and software to manage cases and document reviews.
View Full Description & ApplyYou'll be redirected to the employer's site
