Clinical Review Nurse, RN

9 hours ago


Uniondale, New York, United States TAG MedStaffing Full time
Job Overview

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.
Requirements
  • 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.


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