Nurse - Clinical Review

About the role

Performs utilization review of cases to determine if the request meets medical necessity criteria in accordance with medical policies agreed upon with the Client and any applicable governing body.

Facilitates resolution of escalated cases that may require special handling.

Performs clinical reviews according to the policies and procedures of HealthHelp within the identified State and Federal or Client agreed upon timeframes.

Collaborates with client personnel to resolve customer concerns.

Appropriately identifies and refers quality issues to UM Leadership.

Affords assistance to Physician Reviewers and Medical Directors, as necessary, to ensure compliance with review timeframes.

Maintains written documentation according to HealthHelp’s documentation policy.

Ensures consistency in implementation of policy, procedure, and regulatory requirements in collaboration with Nursing Management.

Keeps current with regulation changes as provided by Compliance Department and Nursing Management.

Adheres to all HIPAA, state, and federal regulations pertaining to the clinical programs.

Provides quality customer service through interaction with providers, administrative staff, and others.

Creates, encourages, and supports an environment that fosters teamwork, respect, diversity, and cooperation with others.

Engages in phone conversations with ordering providers, members, internal staff, primary care physicians (PCPs), and rendering providers as necessary to facilitate the clinical review process and ensure appropriate care decisions.

Effectively utilizes various computer systems and software to manage cases and document reviews.

Promotes business focus which demonstrates an understanding of the company’s vision, mission, and strategy.

Participates in the HealthHelp Quality Management Program, as required.

Adheres to both URAC & NCQA standards pertinent to their job description.

Able to prioritize projects, work independently under pressure, and meet critical deadlines.

Capable of communicating clinical concepts to providers and staff based on guidelines.

Responsibilities

• Performs utilization review of cases to determine if the request meets medical necessity criteria in accordance with medical policies agreed upon with the Client and any applicable governing body.
• Facilitates resolution of escalated cases that may require special handling.
• Performs clinical reviews according to the policies and procedures of HealthHelp within the identified State and Federal or Client agreed upon timeframes.
• Collaborates with client personnel to resolve customer concerns.
• Appropriately identifies and refers quality issues to UM Leadership.
• Affords assistance to Physician Reviewers and Medical Directors, as necessary, to ensure compliance with review timeframes.
• Maintains written documentation according to HealthHelp’s documentation policy.
• Ensures consistency in implementation of policy, procedure, and regulatory requirements in collaboration with Nursing Management.
• Keeps current with regulation changes as provided by Compliance Department and Nursing Management.
• Adheres to all HIPAA, state, and federal regulations pertaining to the clinical programs.
• Provides quality customer service through interaction with providers, administrative staff, and others.
• Engages in phone conversations with ordering providers, members, internal staff, primary care physicians (PCPs), and rendering providers as necessary to facilitate the clinical review process and ensure appropriate care decisions.
• Effectively utilizes various computer systems and software to manage cases and document reviews.
• Promotes business focus which demonstrates an understanding of the company’s vision, mission, and strategy.
• Participates in the HealthHelp Quality Management Program, as required.
• Adheres to both URAC & NCQA standards pertinent to their job description.
• Able to prioritize projects, work independently under pressure, and meet critical deadlines.
• Capable of communicating clinical concepts to providers and staff based on guidelines.

Requirements

• RN, LPN/LVN graduate from an accredited school of nursing
• Current, active unrestricted RN, LPN/LVN license in the state or territory of the U.S.
• Minimum of one (1) year experience in utilization review, or utilization management
• Proficient technical skills in Microsoft Office (Word, Excel, and PowerPoint) and ability to adapt to new healthcare specific software and systems, required
• Experience working with state and federal regulatory and compliance standards, preferred
• Working knowledge of National Coverage Determination (NCD) and Local Coverage Determination (LCD)
• Knowledge of insurance terminology
• Good organizational and time management skills
• Excellent written and verbal communication skills
• Ability to utilize critical thinking skills
• Highly motivated, self-starter who can work efficiently and independently, or as a team member

Qualifications

• RN, LPN/LVN graduate from an accredited school of nursing
• Current, active unrestricted RN, LPN/LVN license in the state or territory of the U.S.
• Minimum of one (1) year experience in utilization review, or utilization management
• Proficient technical skills in Microsoft Office (Word, Excel, and PowerPoint) and ability to adapt to new healthcare specific software and systems, required
• Experience working with state and federal regulatory and compliance standards, preferred
• Working knowledge of National Coverage Determination (NCD) and Local Coverage Determination (LCD)
• Knowledge of insurance terminology
• Good organizational and time management skills
• Excellent written and verbal communication skills
• Ability to utilize critical thinking skills
• Highly motivated, self-starter who can work efficiently and independently, or as a team member

Skills

• Ability to prioritize projects, work independently under pressure, and meet critical deadlines
• Capable of communicating clinical concepts to providers and staff based on guidelines

Benefits

• Medical
• Dental
• Vision
• 401K plan

Pay

The base salary for this position is $65,000 [LVN/LPN], $75,000 [RN] annually. This represents the base pay range that we reasonably expect to offer for this position.

Final compensation will be determined based on a variety of factors, including but not limited to the candidate’s experience, education, skillset, and location.

Geographic location

Overall professional experience

Directly relevant experience

Education and certifications

Industry knowledge and expertise

Skills and competencies

Final compensation

Final compensation will be determined based on a variety of factors, including but not limited to the candidate’s experience, education, skillset, and location.

How to Apply

Please submit your application, including a resume and optional cover letter, through our careers page or email to [email protected].