Clinical Review Nurse

6 days ago

Uniondale, New York, United States Mitchell Martin Full time
Job Title: RN Clinical Review Nurse

At Mitchell Martin, we are seeking a highly skilled RN Clinical Review Nurse to join our team. As a key member of our Clinical Review Department, you will play a critical role in ensuring the delivery of high-quality patient care.

Job Summary:

The RN Clinical Review Nurse will be responsible for reviewing and recommending services requested by providers based on evidence-based medical necessity criteria. This role requires strong clinical knowledge, excellent communication skills, and the ability to work independently in a fast-paced environment.

Key Responsibilities:
  • Process requests for authorization from in-network providers and communicate timely decisions to the Interdisciplinary Team (IDT).
  • Collect, review, and evaluate information necessary to reach prospective, concurrent, and retrospective decisions using objective evidence-based clinical criteria.
  • Suggest alternate care plans, make recommendations, and coordinate with the Provider/IDT for appropriate utilization of services.
  • Document case reviews, associated communications, and outcomes in the electronic case file.
  • Present cases to the site Physician and/or Medical Director for review and determination.
  • Work closely with the Physician and/or Medical Director to ensure timely medical review of specific cases and meet standards for decision turnaround times.
  • Participate in periodic inter-rater reliability testing on medical necessity criteria application.
  • Recognize and refer potential quality of care concerns to Quality Management.
  • Maintain confidentiality of all information in compliance with State and Federal Law and Client policy.
  • Identify and communicate system improvements or individual care issues that would cause failure to provide appropriate care or meet service requirements.
Requirements:
  • BSN required.
  • Minimum of three to five years' experience in a hospital or home care clinical setting.
  • Knowledgeable about Medicare and Medicaid guidelines.
  • Case Management and discharge planning experience is beneficial.
  • Two to three years of Utilization Review experience at a Managed Care Organization is preferred.
  • Proficient in computer programs such as Microsoft Office and Microsoft Excel a plus.
  • Excellent verbal and written communication skills.
  • Excellent problem-solving and analytical skills.
  • Accurate attention to detail with strong organizational skills.
  • Demonstrated ability to manage multiple projects and be flexible.
  • Able to travel to any of the CLHC locations, as needed.

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