Clinical Review Nurse
2 weeks ago
TekWissen Group serves as a workforce management provider across the USA and internationally. Our client operates within the health insurance sector, offering a variety of healthcare coverage options including individual and family plans, dental and vision coverage, as well as employer-sponsored plans.
Position: Clinical Review Nurse
Work Location: Detroit, MI
Duration: 12 Months
Job Type: Contract
Work Type: Onsite Training followed by Remote Work
Department: Utilization Management Program
Responsibilities:
- Conduct thorough medical necessity evaluations utilizing established clinical policies and guidelines for post-acute care services, ensuring appropriateness of care settings and lengths of stay, including handling appeal requests from providers and members.
- Facilitate care coordination throughout the healthcare continuum, which includes outreach to members.
- Offer support and alternative care options for members who are not suitable for post-acute care services, while also assessing discharge readiness for those transitioning to lower levels of care.
- A Bachelor’s degree in nursing, allied health, business, or a related field is preferred.
- A minimum of two (2) to four (4) years of clinical experience is required, which may encompass post-acute care, home health, acute care, discharge planning, case management, and utilization review, particularly with the elderly population in home or post-acute settings.
- Proven clinical expertise and knowledge in patient care and healthcare delivery systems is essential.
- One (1) year of experience in a health insurance plan or managed care environment is preferred.
- A current and unrestricted Michigan Registered Nurse license is mandatory.
- While not required, the following skills may be advantageous depending on the specific assignment:
- Familiarity with Medicare requirements regarding skilled versus non-skilled services in post-acute and home care settings.
- Certification in Case Management.
- Experience managing patients with compromised airways requiring skilled services.
- Knowledge in goal planning and intervention for patients recovering from unexpected or extended hospital stays, including but not limited to conditions such as stroke, hip and femur fractures requiring surgical intervention, sepsis, ventilator dependency, and significant changes in functional ability.
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