Clinical Review Specialist
6 days ago
**About Us:** Hines and Associates is a nationwide, independent leader in personalized managed health care, focused on delivering exceptional services with unparalleled program excellence and cost containment. Our reputation as an industry leader is founded on over three decades of innovative and professional health care expertise. We serve all aspects of the healthcare industry, committed to conserving healthcare dollars while ensuring quality care through effective programs and personalized service.
**Competitive Compensation:** $73,000 - $93,000 per year, depending on experience, plus benefits including medical, dental, vision, long-term care, short-term disability, long-term disability, and company-paid life insurance. Our 401(k) plan features a company match, fully vested after 1 year. Enjoy paid holidays and a remote/hybrid setting (once trained).
**Job Description:** As a Clinical Review Specialist, you will utilize your clinical knowledge and communication skills to obtain patient-specific information regarding patient condition and proposed treatments and procedures. Your role involves determining whether illness and/or proposed services meet acceptable criteria sets and acceptable nursing practice guidelines for outpatient treatment or inpatient confinement. You will certify treatment for confinement when criteria and/or practice guidelines are met, in accordance with health benefit plans, disability, workers' compensation regulations, and state and federal regulations.
**Responsibilities and Performance:** Complete first-level reviews within the scope of practice relevant to the clinical area(s) addressed in the initial clinical review. Demonstrate ability to assess a patient's current medical status, including complications and untoward events, which may require additional intervention. Provide certification of medical, disability, and workers' compensation cases. Maintain knowledge of current advances and trends in medical care, URAC guidelines, Hines policies and procedures, and standards of practice and their revisions.
**Requirements:** Registered Nurse with a valid, unrestricted, current nursing license in the state or territory of the United States where employed. Successful completion of UR nurse orientation program. Minimum of 3 years recent acute clinical practice required, 5 years preferred. Managed care, disability, or workers' compensation experience helpful but not mandatory.
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