Nurse - Clinical Review
About The Position
Performs utilization review of cases to determine if the request meets medical necessity criteria in accordance with medical policies agreed upon with the Client and any applicable governing body. Facilitates resolution of escalated cases that may require special handling. Performs clinical reviews according to the policies and procedures of HealthHelp within the identified State and Federal or Client agreed upon timeframes. Collaborates with client personnel to resolve customer concerns. Appropriately identifies and refers quality issues to UM Leadership. Assists Physician Reviewers and Medical Directors, as necessary, to ensure compliance with review timeframes. Maintains written documentation according to HealthHelp’s documentation policy. Ensures consistency in implementation of policy, procedure, and regulatory requirements in collaboration with Nursing Management. Keeps current with regulation changes as provided by Compliance Department and Nursing Management. Adheres to all HIPAA, state, and federal regulations pertaining to the clinical programs. Provides quality customer service through interaction with providers, administrative staff, and others. Creates, encourages, and supports an environment that fosters teamwork, respect, diversity, and cooperation with others. Engages in phone conversations with ordering providers, members, internal staff, primary care physicians (PCPs), and rendering providers as necessary to facilitate the clinical review process and ensure appropriate care decisions. Effectively utilizes various computer systems and software to manage cases and document reviews. Promotes business focus which demonstrates an understanding of the company’s vision, mission, and strategy. Participates in the HealthHelp Quality Management Program, as required. Adheres to both URAC & NCQA standards pertinent to their job description. Ability to prioritize projects, work independently under pressure, and meet critical deadlines. Capable of communicating clinical concepts to providers and staff based on guidelines. Performs other related duties and projects as assigned to meet business needs.
Requirements
- RN, LPN/LVN graduate from an accredited school of nursing
- Current, active unrestricted RN, LPN/LVN license in the state or territory of the U.S.
- Minimum of two (2) years experience in utilization review, case management, or clinical quality improvement
- Proficient technical skills in Microsoft Office (Word, Excel, and PowerPoint) and ability to adapt to new healthcare specific software and systems, required
- Working knowledge of National Coverage Determination (NCD) and Local Coverage Determination (LCD)
- Knowledge of insurance terminology
- Good organizational and time management skills
- Excellent written and verbal communication skills
- Ability to utilize critical thinking skills
- Highly motivated, self-starter who can work efficiently and independently, or as a team member
Nice To Haves
- Experience working with state and federal regulatory and compliance standards, preferred
Responsibilities
- Performs utilization review of cases to determine if the request meets medical necessity criteria in accordance with medical policies agreed upon with the Client and any applicable governing body.
- Facilitates resolution of escalated cases that may require special handling.
- Performs clinical reviews according to the policies and procedures of HealthHelp within the identified State and Federal or Client agreed upon timeframes.
- Collaborates with client personnel to resolve customer concerns.
- Appropriately identifies and refers quality issues to UM Leadership.
- Assists Physician Reviewers and Medical Directors, as necessary, to ensure compliance with review timeframes.
- Maintains written documentation according to HealthHelp’s documentation policy.
- Ensures consistency in implementation of policy, procedure, and regulatory requirements in collaboration with Nursing Management.
- Keeps current with regulation changes as provided by Compliance Department and Nursing Management.
- Adheres to all HIPAA, state, and federal regulations pertaining to the clinical programs.
- Provides quality customer service through interaction with providers, administrative staff, and others.
- Creates, encourages, and supports an environment that fosters teamwork, respect, diversity, and cooperation with others.
- Engages in phone conversations with ordering providers, members, internal staff, primary care physicians (PCPs), and rendering providers as necessary to facilitate the clinical review process and ensure appropriate care decisions.
- Effectively utilizes various computer systems and software to manage cases and document reviews.
- Promotes business focus which demonstrates an understanding of the company’s vision, mission, and strategy.
- Participates in the HealthHelp Quality Management Program, as required.
- Adheres to both URAC & NCQA standards pertinent to their job description.
- Ability to prioritize projects, work independently under pressure, and meet critical deadlines.
- Capable of communicating clinical concepts to providers and staff based on guidelines.
- Performs other related duties and projects as assigned to meet business needs.
Benefits
- Medical, dental, and vision insurance
- Paid time off (PTO), holidays, and sick leave
- 401(k) with company match or other retirement plan
- Life and AD&D Insurance
- Employee Assistance Program
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
