Clinical Resource Management Nurse

2 weeks ago


Great Neck, New York, United States The Bachrach Group Full time
Job Overview

We are seeking a dedicated Clinical Resource Management Nurse to join our team. This role is essential in ensuring that healthcare services provided to patients are both necessary and appropriate.

Key Responsibilities:
  • Review and Evaluation: Perform thorough evaluations of patient medical records to assess the necessity and suitability of healthcare interventions.
  • Care Coordination: Work collaboratively with healthcare professionals, case managers, and insurance entities to ensure optimal patient care and efficient resource utilization.
  • Regulatory Compliance: Uphold adherence to all relevant regulatory standards, accreditation requirements, and internal policies regarding utilization management.
  • Documentation: Maintain precise records of review outcomes, decisions, and justifications in line with organizational and regulatory standards.
  • Effective Communication: Engage in clear communication with healthcare providers, patients, and insurance representatives concerning review results, recommendations, and authorization processes.
  • Appeals Support: Aid in the development and presentation of appeal cases for denied services, leveraging clinical knowledge and supporting documentation.
  • Educational Outreach: Provide training and resources to healthcare staff on best practices, guidelines, and criteria related to utilization management.
  • Data Analysis: Examine utilization data to uncover trends, identify improvement areas, and explore cost-saving opportunities.
  • Quality Enhancement: Participate in initiatives aimed at improving the efficiency and effectiveness of the utilization review process.
Qualifications:
  • Education: Graduate from an accredited nursing program; BSN preferred.
  • Licensure: Active, unrestricted RN license in the relevant state.
  • Experience: At least 3 years of clinical nursing experience, with a minimum of 2 years in utilization review, case management, or a related area.
  • Certifications: Preferred certifications in Utilization Review (e.g., CPUR) or Case Management (e.g., CCM).
  • Skills: Exceptional clinical assessment and critical thinking abilities. Strong communication, negotiation, and problem-solving skills. Proficient in electronic health records (EHR) and utilization management software.
  • Knowledge: Comprehensive understanding of healthcare regulations, medical necessity criteria (e.g., InterQual, Milliman), and insurance authorization protocols.
Working Conditions:
  • Office-based role with occasional travel to healthcare facilities as required.
  • Standard working hours with potential for flexibility based on workload and organizational demands.
  • Capacity to manage a high volume of reviews while meeting deadlines.
Benefits:
  • Competitive salary and comprehensive benefits package.
  • Opportunities for continuing education and support for professional certification.
  • A collaborative and supportive workplace culture.


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