Clinical Reviewer (RN)
About The Position
As the Clinical Reviewer, you will be responsible for the review and processing of all requests for Independent Reviews from External Agencies in accordance with contractual guidelines. Upon receipt of the electronic medical records, communicate with contractors, providers and beneficiary/representatives. Duties include but are not limited to: Performing case reviews utilizing regulatory guidelines criteria and clinical knowledge for medical necessity and quality of care issues; formulate a case summary and the review questions for the Physician Reviewer based upon the External Agency’s concern(s), reviewing physician determinations, ensuring all categories of concern have been addressed and preparing written correspondences to contractors, providers and beneficiaries/representatives.
Requirements
- Licensed Registered Nurse, required (open to any RN state license).
- Graduate of a School of Nursing, required.
- Bachelor of Science in Nursing (BSN), required.
- A minimum of three (3) years clinical experience in an acute care setting or related experience, required.
- Experience in utilization and quality reviews, required.
- Ability to interact with providers, internal/external customers and representatives.
- Excellent communication skills (both verbal and writing) with a professional demeanor.
- Ability to work independently, as well as in a team environment.
- Excellent time management/prioritization skills to meet contractual deadlines while maintaining a high level of quality work to meet customer satisfaction and standards.
- Strong clinical critical thinking skills.
- Advanced skills and knowledge of standard EHR applications, office technology and Microsoft applications including Word, Excel, and PowerPoint.
- Ability to handle sensitive and confidential information.
Nice To Haves
- Experience in managed care, quality management and peer review, preferred.
Responsibilities
- Review and process all requests for Independent Reviews from External Agencies in accordance with contractual guidelines.
- Communicate with contractors, providers, and beneficiary/representatives upon receipt of electronic medical records.
- Perform case reviews utilizing regulatory guidelines criteria and clinical knowledge for medical necessity and quality of care issues.
- Formulate a case summary and review questions for the Physician Reviewer based upon the External Agency’s concern(s).
- Review physician determinations, ensuring all categories of concern have been addressed.
- Prepare written correspondences to contractors, providers, and beneficiaries/representatives.
Benefits
- IPRO is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, disability, protected veteran status or military status, or any other category protected under applicable law.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
