JOB PURPOSE: 

Under the direction of the Senior Director of Clinical Review, the Clinical Review Nurse is responsible for complying with the day-to-day operations of the Clinical Review Department. Responsibilities include reviewing, recommending and providing authorization for services requested by providers based on evidence-based medical necessity criteria. The Senior Director of Clinical Review will monitor the Clinical Review Nurse’s activities and outcomes, ensuring compliance with established regulatory and contractual requirements. The position will serve as a liaison between the company and its participants and providers. 

JOB RESPONSIBILITIES: 

Processes requests for authorization from in-network providers and communicates in a timely manner when the decision has been made by the Interdisciplinary Team (IDT).  Collects, reviews, and evaluates information necessary to reach prospective, concurrent and retrospective decisions using objective evidence-based clinical criteria.  Suggests alternate care plans, makes recommendations and coordinates with the Provider/IDT for appropriate utilization of services.  Documents case reviews, associated communications, and outcomes in the electronic case file.  Presents cases to the site Physician and/or Medical Director for review and determination. Works closely with the Physician and/or Medical Director to ensure that medical review of specific cases occurs timely and meets standards for decision turnaround times.  Participates in periodic inter-rater reliability testing on medical necessity criteria application.  Recognizes and refers potential quality of care concerns to Quality Management.  Maintains confidentiality of all information in compliance with State and Federal Law and Facility policy.  Identifies and communicates system improvements or individual care issues that would cause failure to provide appropriate care or meet service requirements.  Performs other duties as assigned.
 

QUALIFICATIONS: 

Education: BSN required 

Experience: 

Minimum of three to five (3 - 5+) years’ experience in a hospital or home care clinical setting.  Knowledgeable about Medicare and Medicaid guidelines.  Case Management and discharge planning experience is beneficial.  Two to three (2 - 3) years of Utilization Review experience at a Managed Care Organization is preferred. 

Other: 

Proficient in computer programs such as Microsoft Office and Microsoft Excel a plus.  Excellent verbal and written communication skills.  Excellent problem solving and analytical skills.  Accurate attention to detail with strong organizational skills.  Demonstrated ability to manage multiple projects and be flexible.  Able to travel to any of the Clinic locations, as needed. 

Physical Requirements 

Individuals must be able to sustain specific physical requirements essential to the job. This includes, but is not limited to: 

Standing – duration of up to 6 hours a day.  Sitting/Stationary positions – sedentary position for up to 6-8 hours a day for consecutive hours/periods of time.  Lifting/Push/Pull – up to 50 pounds of equipment, baggage, supplies, and ability to lift patients safely, using OSHA guidelines, etc.  Bending/Squatting – have to be able to bend or squat to care for patients safely, use medical supplies, etc.  Stairs/Steps/Walking/Climbing – must be able to maneuver stairs safely, climb up/down and walk to access work areas Position requires an individual to be able to travel, walk between sites/locations and work areas throughout the day. Agility/Fine Motor Skills - Must demonstrate agility and fine motor skills to operate and activate equipment, devices, instruments, and tools (i.e., typing, use of medical supplies, equipment, etc.)  Sight/Visual Requirements – must be able to visually assess patients, read orders and type/write documentation, etc., accurately.  Audio Hearing and Motor Skills (language) Requirements – must be able to listen attentively and document information from patients, community members, providers, etc., and intake information through audio processing with accuracy. In addition, must be able to speak comfortably and clearly with language motor skills for customers to understand the individual.  Cognitive Ability – Must be able to demonstrate good decision-making, reasonableness, cognitive ability, rational processing, and analysis to satisfy essential functions of the job. 

Disclaimer: Responsibilities and tasks outlined in this job description are not exhaustive and may change as determined by the needs of the company.

*Additional Salary Detail The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining a team member's base salary and/or rate, several factors may be considered as applicable (e.g., location, specialty, service line, years of relevant experience, education, credentials, negotiated contracts, budget and internal equity).