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Clinical Review Nurse, RN
2 months ago
We are seeking a skilled Clinical Review Nurse to join our team at TAG MedStaffing in a hybrid role. In this position, you will ensure smooth daily operations of the Clinical Review Department, including reviewing and authorizing provider services, with a focus on evidence-based medical necessity and regulatory compliance.
Key Responsibilities- Authorization Processing: Handle requests for service authorizations from in-network providers, ensuring timely communication of decisions made by the Interdisciplinary Team (IDT).
- Clinical Review: Collect, review, and evaluate necessary information to make decisions on prospective, concurrent, and retrospective cases using evidence-based criteria.
- Care Coordination: Suggest alternative care plans and collaborate with providers and the IDT to optimize service utilization.
- Case Documentation: Maintain accurate records of case reviews, communications, and outcomes in electronic case files.
- Medical Review: Present cases to the site Physician and/or Medical Director for timely review and determination.
- Quality Assurance: Participate in inter-rater reliability testing and refer potential quality of care concerns to Quality Management.
- Education: BSN required.
- Experience: 3-5+ years of Clinical experience in a Hospital or Home Care setting.
- Preferred Experience: 2-3 years of Utilization Review experience at a Managed Care Organization preferred.
- Technical Skills: Proficiency in Microsoft Office and Excel.
- Travel: Ability to travel to various sites as required.
