Clinical Review Nurse
7 days ago
Job Summary:
We are seeking a Clinical Review Nurse to join our Utilization Management team. This role is responsible for reviewing inpatient stays and determining medical necessity using nationally recognized levels of care guidelines.
About the Role:
- Perform prospective, concurrent, and retrospective utilization reviews to determine medical necessity and approve long-term care members' treatment plans.
- Conduct clinical reviews of claims for medical necessity, coding accuracy, medical policy compliance, and contract adherence.
- Ensure discharge planning at appropriate levels of care for members' needs and acuity, including post-acute needs and quality-appropriate discharge planning.
- Prepare and present cases to Medical Directors for oversight and necessity determination, communicating determinations to providers and/or members.
- Develop and review member-centered documentation and correspondence reflecting determinations, identifying potential quality-of-care issues and intervening as clinically appropriate.
- Refer acute inpatient needs affecting discharge to Case Management when necessary.
- Maintain quality and productivity metrics for all casework.
Requirements:
Bachelor's degree or equivalent experience. Strong communication and computer navigation skills required.
Estimated Salary Range: $85,000 - $115,000 per year, depending on experience.
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