JOB TITLE: Clinical Review RN (Medicaid Cost Outlier)

IDEAL BACKGROUND: At least 5 years of recent Acute Care/Med Surg experience. Utilization Review (Interqual/MCG) experience a PLUS.

GENERAL RESPONSIBILITIES: This individual will complete the full spectrum of activities related to Utilization or Quality reviews as assigned. They will utilize their knowledge and expertise of the review program to conduct clinical level review, supporting Medical Review Analysts, and Physician Consultants to ensure an appropriate and accurate process.

DUTIES:
1. Conduct utilization reviews up to and including the appeal level. This includes chart screen, complete electronic worksheets, enter required information and make level one denial decisions when necessary.
2. Conduct quality and clinical study data collection reviews. This includes chart review, complete detailed electronic data worksheets.
3. Act as a resource for the administrative staff in training, problem solving, and clarifying procedures. Will provide technical assistance and conduct/participate in staff huddles.
4. Participate in collaborative training specific to clinical study objectives.
5. Other activities as may be deemed necessary.

QUALIFICATIONS:
1. Licensed as a Registered Professional Nurse in New York State.
2. Knowledge and experience with electronic medical records including utilization, quality, and clinical charting.
3. Ability to oversee, problem solve and work collaboratively with peers, medical, analytical, and administrative support staff.
4. Excellent written and verbal skills.
5. Ability to work independently with little supervision.
6. Ability and desire to be flexible, innovative, and creative.

EDUCATION & EXPERIENCE:
1. Baccalaureate degree in Nursing or graduate of an approved Registered Professional Nurses training program and licensed to practice in the State of New York.
2. A minimum of two years experience in an acute care facility preferably in medical surgical AND 1-3 years experience in acute care utilization review, preferable.

LOCATION: in office in Jericho, NY
***there is a free shuttle from the Jericho LIRR station + parking onsite

SCHEDULE: Monday-Friday, start time between 7am-9am (40 hours) or 4x10s

PAY: $50-55/hr

DURATION: long term open ended contract includes benefits, sick time, 401k, weekly pay

^*We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state, and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA).

^*As a job position within our Care Management division, a successful completion of a background check may be required as a condition of employment. This requirement is directly related to essential job functions including but not limited to: accessing financial and confidential information, access and handling of patient medical records, providing medical care inside a patient’s residential address, driving, prescription and other drug access and administration, and working with vulnerable populations, such as, minors, elderly and those with physical or mental disabilities. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.