Clinical Review Nurses

2 weeks ago

Flushing, United States Mitchell Martin Full time

A Day treatment facility located in Flushing, NY is looking for an Clinical Review Nurses.

Type: Contract
Schedule: M-F 8:30am-5:30pm -1 Hour Break, as well as two 15-minute breaks
Location: Flushing, NY

JOB PURPOSE:
The Clinical Review Nurse is responsible for making appropriate and correct clinical decisions for appeals outcomes within compliance standards.
Responsible for determining the medical appropriateness of inpatient and outpatient services by reviewing clinical information and applying evidence-based guidelines with state, federal, Managed Long-Term Care, and PACE regulations.
The Clinical Review Nurse will manage his/her own caseload and is accountable for investigating and resolving participant or provider-initiated appeal cases, including clinical claim appeals from participating and non-participating providers.
The position works closely with the Medical Director.

RESPONSIBILITIES:
Performs clinical/medical reviews of previously denied cases in which a formal appeals request has been made.
Interacts with clients providers, participants, and internal service & care delivery teams to obtain necessary information and communicating appeal determinations timely.
The Clinical Review Nurse works closely with the A&G Specialists to ensure accurate entry of a case for tracking purposes.
Works independently, prioritizes case deliverables, and stays current on changes in the healthcare system that may affect clinical decisions.
Excellent knowledge of all relevant PACE and applicable Federal and State regulatory requirements and guidelines, knowledge of policies and procedures, and individual judgment and experience to assess the appropriateness of services, items provided, length of stay and level of care.
Collects relevant medical information and applies the appropriate evidence-based guidelines and medical policy for denied services associated with appeal cases.
Follows documentation guidelines for clear and concise decision-making within EMR appeals tracking platform.
Maintains appeal cases in a complete, accurate, and organized fashion for audit readiness.
Collaborates with regional medical directors and upon direction, communicate appropriately with the regulator/team liaison.
Meets required decision-making timeframes, including promptly triggering escalation for cases requiring physician review.
pplies appropriate criteria on PAR and Non-PAR (contracted and non-contracted) provider claim appeal cases.
Reviews medically appropriate clinical guidelines and other appropriate criteria with Chief Medical Officer/ Medical Director on denial decisions.
The end- to-end process requires the Clinical Review Nurse to independently:
Research issues
Reference and understand CenterLight internal policies and procedures to frame decisions
Interpret PACE/CMS regulations
Resolve cases and make critical decisions
Update file documentation such as EMR, case notes and case summary
Manage all duties within regulatory timeframes
Prepares cases for Medical Director Review or External Physician Advisor ensuring that all pertinent information (i.e., case summary, contract information, internal and external responses, diagnosis, and CPT codes and descriptions) has been obtained during investigation and is presented in the Appeal Summary Review Sheet as part of the case
Prepares cases for Maximus Federal Services, Fair Hearing, and External Appeal through all levels of the appeal process.
Prepares and presents cases in conjunction with the Medical Director and IDT team for Administrative Law Judge pre-hearings meetings.
Represents and presents cases effectively to Judicial Fair Hearing Officer during Fair Hearings as may be required.
Serves as a clinical resource for Medical staff, IDT, and Participant/Provider Inquiries/Appeals.
Identifies and reports quality of care issues.
Communicates effectively to hand-off and pick-up work from colleagues as necessary.
dditional duties as assigned

QUALIFICATIONS:
Education: Graduate from an Accredited School of Nursing. Bachelor's degree in Nursing preferred.
Licensure: Nursing

Experience:
3-5 years' clinical nursing experience, with 1-3 years in a managed care healthcare setting with experience clinical practice with experience in appeals & grievances or claims processing
Knowledgeable about Medicare (CMS) PACE and Medicaid MLTC regulations Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment

Other:
Requires excellent verbal and communications skills
Requires excellent organizational skills
Requires good PC skills and ability to manage applicable software. Ability to work independently on several computer applications such as Microsoft Word and Excel, as well as corporate email
Requires good interpersonal skills and the ability to work with all levels of employees

Please email: JAbbate@hcmmi.com

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