Clinical Care Reviewer Registered Nurse

Job Description

Job Summary 

Under the direction of the unit Supervisor, the Clinical Care Reviewer is responsible for completing medical necessity reviews. Using clinical knowledge and nursing experience, the nurse reviews provider requests for inpatient and outpatient services, working closely with members and providers to collect all information necessary to perform a thorough medical necessity review. It is within the nurse’s discretion to send requests for additional information and/or request clarification. The nurse will use his/her professional judgment to evaluate the request to ensure that appropriate services are approved and recognize care coordination opportunities and refer those cases as needed. The nurse will apply medical health benefit policy and medical management guidelines to authorize services and appropriately identify and refer requests to the Medical Director when guidelines are not met. The nurse will maintain current knowledge and understanding of the laws, regulations, and policies that pertain to the organizational unit’s business and uses clinical judgment in their application.

Qualifications

Experience and Skills

Three to five years - 3 or more years’ experience in a related clinical setting.

Registered Nurse

Registered Nurse graduated from an accredited program.

Current unrestricted Iowa Registered Nurse license.

Valid Driver’s License and reliable automobile transportation for on-site assignments and off-site work related activities...

Additional Information

Competencies

Excellent oral and written communication skills.

Ability to identify problems and recommend solutions.

Self-directed/Ability to work independently.

Excellent decision making skills.

Excellent time management skills, prioritizing work and meeting timelines.

Ability to advocate for member/member family needs.

Dedicated to meeting the expectations and requirements of internal and external customers.

Obtains continuing education required to maintain professional licensure.

Ability to achieve required performance results on all audits and Inter Rater Reliability (Peer to Peer).

Riya Khem

Clinical Recruiter

Integrated Resources, Inc.

IT Life Sciences Allied Healthcare CRO

Certified MBE |GSA - Schedule 66 I GSA - Schedule 621I

DIRECT # - 732 662 4717| (W) # 732-549-2030 - Ext - 311 |(F) 732-549-5549