Clinical Nurse Reviewer

VGM Group, Inc

3d•Hybrid

About The Position

Review physician orders and clinical notes to complete a detailed peer clinical review that focuses on appropriate care and patient outcomes. In collaboration with the treating provider, you will use your clinical expertise and clinical guidelines to report on the appropriateness and quality of patients’ current care as well as make recommendations on revised plan of care (e.g. level of care, frequency and duration).

Requirements

Active LPN license in good standing, in a Nurse Licensure Compact (NLC) state such as Iowa. If outside the NLC, licensure is required for at least one applicable state in which business is conducted
Preferred two (2) years of experience in an acute care setting, home care setting, and/or physician office or ambulatory setting
Must comply with continuing education per Company, regulatory, contractual, and accreditation requirements
Ability to multitask and prioritize workflow is a dynamic, fast-paced work environment
Possess strong time management and organization skills
Work well under pressure and be punctual
Flexible with the ability to routinely adapt to change
Team player with excellent communication skills
Maintain a courteous and professional demeanor in all customer interactions
Ability to learn the Company’s care management platform and adapt to any system changes
Knowledge of Microsoft Word, Excel, and Outlook
Working at a physical desk, moving about the office and facility as needed for work
Operation of office machinery and equipment
Visual abilities to include reading, distance vision, and peripheral vision

Nice To Haves

Active RN licensure in good standing preferred

Responsibilities

Complete assigned clinical peer reviews (i.e. 30daysummary) per SOP with appropriate turnaround times and comprehensiveness of review findings and recommendations, to include review of evaluation and ongoing 30-120 day reviews as determined based on initial peer review by nurse and per acuity level
Review evaluations, physician orders, and progress notes to assess if the services requested or that are ongoing are adequate and appropriate for current patient status
Review care and recommend cost savings and/or step-down care opportunities
Perform peer calls and communicate with treating providers, referring physicians and patients to achieve non-contentious plan of treatment revisions when appropriate
Communicate with Clinical Coordinators (CCs), or when necessary, request Patient Care Coordinators (PCCs) to obtain additional information needed to complete reviews
Communicate with PCCs and CCs when the review is completed and document any recommended revisions to plan of treatment and needed follow-up. Maintain thorough, up-to-date documentation on each review
Provide clinical expertise and review on adhoc basis for escalated cases and/or questions from Adjusters, Case Managers, or other internal departments (I.e. billing, operations, account management, marketing, etc.)
Provide clinical intake support in collaboration with PCCs and external parties (e.g. discharge planners, NCM) as needed to assist in determining initial staffing needs for new referrals
On a rotational basis, maintain on-call nurse hours as needed. There is rotation for department on-call and back-up schedule per department procedure
Provide oversight and monitor the Quality Improvement and Utilization Management activities of non-clinical staff, as applicable, to ensure regulatory and accreditation compliance
Follows strict confidentiality and HIPAA privacy and security guidelines
Maintain knowledge of various healthcare industry billing and/or coding terminologies such as ICD-10, HCPCS, CPT, modifiers, and various Medicare LCDs
Any other duties as deemed appropriate by department management / Clinical Nurse Review Manager