Clinical Reviewer

1 week ago


Pontiac, Illinois, United States Guidehealth Full time
Job Description

As a Utilization Nurse, you will perform utilization review services in compliance with federal and state regulations, and the URAC standards for client members seeking healthcare treatment and services. Your responsibilities will include obtaining, analyzing, and documenting all supporting clinical information within the documentation record, completing timely reviews of healthcare services, and communicating with the Medical Director and Peer Reviewer(s) for cases requiring review of medical necessity, appropriate treatment, intensity/number of inpatient and outpatient treatment or quality of care issues.

You will also be responsible for initiating referrals of targeted patients into organized disease management programs, managing and documenting after-hours phone calls from members and providers, maintaining confidentiality of member information, case records, and file entries, participating in quality management activities, and assisting with coordination and design development of clinical and client-specific reports.



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