Full-timeEstimated: $60,000 - $88,000 a year
- Documentation review
- Analysis skills
- Acute care
- Utilization management
Full Job Description
The Clinical Review Nurse is responsible for providing clinically efficient and effective outpatient utilization management. Reviews prior authorization requests for appropriate care and setting by following evidence based clinical guidelines, medical necessity criteria and health plan guidelines. Reviews and applies hierarchy of criteria to all outpatient referral and preauthorization requests from the PCP’s and specialists that require a medical necessity determination. Is involved in assuring that the patient receives high-quality cost-effective care. Uses sound clinical judgement and managed care principles in the coordination of care. Prepares any case that does not meet medical necessity guidelines for medical appropriateness of procedure, service or treatment for review with the Medical Director for a decision.
Maintains clinical expertise and knowledge of scientific progress in nursing and medical arena and incorporates this information into the clinical review and care coordination processes.
Performs clinical review for appropriate utilization of medical services by applying appropriate medical necessity criteria guidelines.
Authorizes healthcare services in compliance with contractual agreements, Health Plan guidelines and appropriate medical necessity criteria.
Documents clinical reviews in care management system. Provides accurate and timely documentation and supporting rational of decision in care management system.
Utilizes care management system and resources to track and analyze utilization, variances and trends, patient outcomes and quality indicators.
Researches and prepares clinical information for case review with Physician Leadership for patient treatment and care planning.
Utilizes knowledge of resources available in the health care system to assist the physician and patient effectively.
Identifies members who are appropriate for care coordination programs and collaborates with the Medical Management team for care coordination of the member’s needs along the continuum of care.
Successfully completes the Interrater Reliability Testing to ensure consistency of review and application of criteria.
Meets timeliness standards for referral and prior authorization activities.
Serves as an advocate for all providers and their patients.
Demonstrates a positive attitude and respect for self and others and responds in a courteous manner to all customers, internal and external.
Maintains the confidentiality of all company procedures, results, and information about patients, contracts, and all other proprietary information regarding copmany business.
Performs other duties as required or requested in a positive and helpful manner to enable the department to achieve its goals.
HIPAA Security Level: High access to systems/patient information.
Supervisory Duties: None
Work Environment/Schedule: Office environment, some remote option. Full time Monday thru Friday 8 am to 5 pm. Must have the ability to push, lift, or pull objects up to 40 pounds, using proper body mechanics. Requires sitting, standing, and general movement in the office.
Knowledge / Skills / Abilities:
Knowledge of Medicare/Medicaid and InterQual guidelines.
Ability to research and prepare clinical information for case review with Physician Leadership for patient treatment and care planning is required.
Ability to provide accurate and timely documentation of clinical review and supporting rational of decision in care management system.
Strong verbal and written communication skills with attention to detail.
Possesses excellent customer service and communication skills.
Employs analytical skills necessary for quality case management, utilization review, and quality improvement to meet organizational objectives.
Able to take initiative to identify potential or actual obstacles and works with others to develop solutions.
Ability to think and work independently with minimum supervision.
Able to perform various computer software applications with an intermediate level of competence.
RN with minimum of 3-5 years in acute care setting preferred.
Previous utilization/case management and/or managed care experience preferred.
Current unrestricted Colorado RN license: BSN preferred.