Clinical Review Nurse
1 month ago
Mitchell Martin, Inc. is seeking a skilled RN Clinical Review Nurse to join our team in Uniondale, NY.
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 will serve as a liaison between the client and its participants and providers, ensuring compliance with established regulatory and contractual requirements.
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 meets 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.
- 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.
- 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.
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Clinical Review Nurse
3 weeks ago
Uniondale, New York, United States Mitchell Martin;Mitchell Martin, Inc. Full timeJob Title: RN Clinical Review NurseWe are seeking a highly skilled and experienced RN Clinical Review Nurse to join our team at Mitchell Martin, Inc. in Uniondale, NY.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. The successful...
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Clinical Review Nurse
3 weeks ago
Uniondale, New York, United States Mitchell Martin Full timeJob Title: RN Clinical Review NurseMitchell Martin is seeking a skilled RN Clinical Review Nurse to join our team in Uniondale, NY.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 will serve as a liaison between Mitchell...
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Clinical Review Nurse
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Uniondale, New York, United States Mitchell Martin Full timeJob Title: RN Clinical Review NurseAt 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...
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Clinical Review Nurse
1 month ago
Uniondale, New York, United States Mitchell Martin Full timeJob Title: RN Clinical Review NurseAt 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...
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