Clinical Review Nurse

Position Summary:

This role involves reviewing service requests from providers, determining medical necessity based on evidence-based criteria, providing authorization for services, and managing day-to-day operations. The Clinical Review Nurse acts as a liaison between participants and providers, ensuring compliance with regulatory and contractual requirements.

Key Responsibilities:

• Review and process service authorization requests from in-network providers.
• Communicate decisions made by the Interdisciplinary Team (IDT) in a timely manner.
• Collect, evaluate, and analyze information to make prospective, concurrent, and retrospective decisions using evidence-based criteria.
• Suggest alternate care plans and collaborate with the Provider/IDT for appropriate service utilization.
• Document case reviews, communications, and outcomes in the electronic case file.
• Present cases to the site Physician and/or Medical Director for review and determination.
• Ensure medical reviews meet standards for decision turnaround times.
• Participate in inter-rater reliability testing on medical necessity criteria application.
• Identify and report potential quality of care concerns to Quality Management.
• Maintain confidentiality in compliance with State and Federal Law and CenterLight Healthcare policies.
• Identify and communicate system improvements or issues affecting care or service requirements.
• Ability to travel between clinic locations to perform duties.
• Perform other duties as assigned.

Requirements:

Education: BSN required.

Experience:

• 3-5 years of clinical experience in a hospital or home care setting.
• Knowledge of Medicare and Medicaid guidelines.
• Experience in case management, discharge planning, and utilization review at a Managed Care Organization (2-3 years preferred).

Skills:

• Proficiency in Microsoft Office and Excel.
• Strong verbal and written communication skills.
• Excellent problem-solving, analytical, and organizational skills.
• Ability to manage multiple projects and adapt to changing needs.
• Willingness to travel to various locations as needed.

Schedule:

• Monday to Friday, 8:30 AM - 5:30 PM (40 hours per week).

This position offers an opportunity to apply clinical expertise in a managed care environment, ensuring that participants receive appropriate and necessary care while adhering to regulatory standards.

Medix is acting as an Employment Business in relation to this vacancy.