Clinical Review Registered Nurse

Job Title: Clinical Review Registered Nurse

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SUMMARY:

• Our Client is looking for a Clinical Review Registered Nurse to support operations within its Utilization Management team.
• This is a full-time (40 hours, M-F) remote opportunity for a 1-3 month duration with potential to extend as needed.
• This position executes utilization management processes to ensure the delivery of medically necessary and appropriate, cost-effective and high-quality care through the performance of clinical reviews.
• Reviews requests against standardized medical necessity and appropriateness criteria for an initial and a continued service authorization.
• Identifies questionable cases and refers to superior or a medical director for review.
• There is no travel required for this role.

RESPONSIBILITIES:

• This position executes utilization management processes to ensure the delivery of medically necessary and appropriate, cost-effective and high-quality care through the performance of clinical reviews.
• Reviews requests against standardized medical necessity and appropriateness criteria for an initial and a continued service authorization
• Identifies questionable cases and refers to superior or a medical director for review
• Perform related duties as required or directed

PRIMARY RESPONSIBILITIES:

• Conduct clinical reviews of all prior approval, post service reviews, customer service and claim requests
• Determine adequacy of clinical elements of clinical information submitted
• Determine essential elements of clinical information for decision-making and request same as appropriate
• Make determinations based on medical policy, evidence-based guidelines, and medical necessity
• Communicate directly with requesting providers to obtain additional clinical information as needed in order to make utilization management decisions.
• Review late and out of network prior approval / referral authorizations for appropriateness and make determination on benefit level based on medical necessity
• Provide timely and accurate review for procedure/service appropriateness, reconsideration, and appeals based on Rule 9-03, DRF, and NCQA Standards
• Perform monthly audits related to prior approval processes as well as weekly guidelines to confirm medical necessity and appropriateness of reviewed services
• Use sound clinical judgment along with appropriate review criteria and practice guidelines to confirm medical necessity and appropriateness of reviewed services
• Provide support to Provider Relations and Provider Reimbursement in regard to clinical issues relating to new procedure, coding, pricing and provider communications
• Provide appropriate and timely referrals to the medical director. Identify and report any potential quality of care of services issue to the medical director.
• Perform timely case review information, case entry and updates to case file in the appropriate systems
• Participate in medical policy committee including research and development of policies and collaboration with participating provider
• Assist in review of health service delivery and utilization and cost data
• Determine through clinical review members that would potentially benefit from case management. Initiate referrals to triage to assess these members for effective case management intervention
• Determine and interpret member eligibility, coverage and available benefits. Contribute to member and provider satisfaction within program and organization
• Assist the claims payer in accurate adjudication of care management approved services as needed

QUALIFICATIONS:

• RN with Vermont License required
• Also open to candidates who have a compact license
• BSN desired
• 5-7 years of clinical practice required
• 1-3 years of insurance related experience desired
• Must be willing to participate in on-going CEU training

Top 3 Required Skills/Experience:

1. Subject Matter Expertise:
   1. Strong knowledge base in health care delivery systems, health insurance, medical care practices and trends, regulatory and accreditation agencies/standards, and provider network management
   2. Strong knowledge of all Plan products and services benefits that effect clinical decision making
   3. Strong knowledge of clinical nursing practice
2. Computer Skills:
   1. Proficient in all Microsoft Office applications
   2. Proficient in CPT, HCPCS coding and ICD-10 diagnosis codes
   3. Proficient in specialized computer applications preferred including SalesForce Health Cloud, Acuity, Microsoft CRM, Onbase (or similar document mgt system), Jira
3. Analytical Skills:
   1. Strong analytical skills, including statistical data analysis

Required Skills/Experience – The rest of the required skills/experience. Include:

• Communication Skills – Strong written and oral communication skills
• Interpersonal Skills – Strong interpersonal skills
• Organizational Abilities – Strong organizational skills
• 5 – 7 years of clinical practice required

Preferred Skills/Experience – Optional but preferred skills/experience. Include:

• 1- 3 years of insurance related experience desired
• Willing to participate in required on-going CEU training

Education/Certifications – Include:

• Licensed RN ; BSN desired; Licensed in compact state desired

Supervision Received – Discretion and Judgment:

• Is expected to regularly use discretion and judgment to make decisions without approval such as planning projects, analyzing accounts, solving problems, or improving processes.

Nature of Duties:

• Primary duties are non-manual in nature (i.e., call handling, accounting)

Focus of Work:

• Primary duties are directly related to general business operations (nearly all of Our Clients)

Knowledge Requirements:

• Ability to perform the job duties requires sue of advance knowledge acquired by a lengthy course of study and/or instruction.

Physical Demands in Performing Essential Job Functions (amount of time):
This section is to comply with the Americans with Disabilities Act (ADA):

• Stand – 1/3
• Walk – 1/3
• Talk to hear – 2/3
• Sit – 2/3
• Reach with hands and arms – 1/3
• Push/pull – 1/3
• Stoop, kneel, crouch or crawl – 1/3
• Fine dexterity – 1/3 to 2/3
• Repetitive use of hands – 2/3
• Visual activity – 2/3
• Aural acuity – 2/3

The above is intended to describe the general contents and requirements of work being performed by people assigned to this position. Nothing in this position description of Our Client’s right to assign or reassign duties and responsibilities to this position at any time.

OpTech is an equal opportunity employer and is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, pregnancy, status as a parent, disability, age, veteran status, or other characteristics as defined by federal, state or local laws. https://www.optechus.com/eeo_self_identification/