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Clinical Review Nurse
2 months ago
Hines & Associates Inc. is a nationwide, independent leader in personalized managed healthcare, focused on delivering comprehensive services with program excellence and cost containment. Our reputation as an industry leader is founded on over three decades of innovative and professional healthcare excellence.
What We Offer- Competitive Compensation and Benefits: We offer a competitive salary and benefits package, including medical, dental, vision, long-term care, short-term disability, long-term disability, and company-paid life insurance.
- 401(k) Plan with Company Match: Our 401(k) plan comes with a company match, fully vested after one year.
- Work-Life Balance: We prioritize work-life balance, offering a remote/hybrid setting (once trained) and a Monday-to-Friday schedule.
- Paid Holidays: Enjoy paid holidays and a healthy work environment.
This role involves utilizing clinical knowledge and communication skills to obtain patient-specific information regarding patient condition and proposed treatments and procedures. The successful candidate will determine if illness and/or proposed services meet acceptable criteria sets and acceptable nursing practice guidelines for outpatient treatment or inpatient confinement.
Key Responsibilities- First-Level Reviews: Complete first-level reviews within the scope of practice relevant to the clinical area(s) addressed in the initial clinical review.
- Clinical Assessment: Assess a patient's current medical status, including complications and untoward events, which may require additional intervention.
- Certification of Medical Cases: Provide certification of medical, disability, and workers' compensation cases.
- Knowledge of Criteria Sets: Demonstrate a thorough understanding of criteria sets and their limitations, including when a second-level review is required.
- Communication: Communicate effectively with hospital staff, physicians, other providers, and Hines customer contacts in a competent, calm, effective, and professional manner.
- Registered Nurse: A valid, unrestricted, current nursing license in the state or territory of the United States where employed is required.
- UR Nurse Orientation Program: Successful completion of the UR nurse orientation program is mandatory.
- Acute Clinical Practice: A minimum of three years of recent acute clinical practice is required, with five years preferred.
- Managed Care Experience: Managed care, disability, or workers' compensation experience is helpful but not mandatory.
