Clinical Review RN PRN

Cooper University Hospital•Camden, NJ

2d•$37 - $61•Onsite

About The Position

Utilizes Payer specific screening tools as a resource to assist in the determination process regarding level of service and medical necessity. Performs utilization review in accordance with all state mandated regulations. Consults with Physician Advisor to discuss medical necessity, length of stay, and appropriateness of care issues. Identify and manage concurrent and retroactive denials through communication with attending physicians, case management, multidisciplinary team, external physician resource group and payers. Completes documentation of review and denial processes in the EPIC Case Management Module. Responds to requests from the payer for all required information and treatment plans. Reviews and validates physician’s orders, reports progress and unusual occurrences on patients to the payer.

Requirements

3-5 years of recent clinical experience, preferably in area of population specialty.
Knowledge and understanding of disease protocols and clinical pathways for commercial and government payors.
Strong communication (written and verbal) skills required.
Critical thinking skills required.
Professional and effective presentation skills required.
Current NJ-RN License required.

Nice To Haves

Experience in utilization management or review preferred.
Familiarity with Interqual and Millimen guidelines and regulatory mandates preferred.
Bachelor’s degree in Nursing preferred.

Responsibilities

Utilize Payer specific screening tools to determine level of service and medical necessity.
Perform utilization review in accordance with state mandated regulations.
Consult with Physician Advisor regarding medical necessity, length of stay, and appropriateness of care.
Identify and manage concurrent and retroactive denials through communication with various stakeholders.
Complete documentation of review and denial processes in the EPIC Case Management Module.
Respond to payer requests for information and treatment plans.
Review and validate physician's orders.
Report patient progress and unusual occurrences to the payer.