RN - Clinical Care Reviewer UM

Job Summary

The primary purpose of the job is to:

Under the direction of the unit Supervisor, the Clinical Care Reviewer is responsible for completing medical necessity reviews. Using clinical knowledge and nursing experience, the nurse reviews provider requests for inpatient and outpatient services, working closely with members and providers to collect all information necessary to perform a thorough medical necessity review. It is within the nurse’s discretion to send requests for additional information and/or request clarification. The nurse will use his/her professional judgment to evaluate the request to ensure that appropriate services are approved and recognize care coordination opportunities and refer those cases as needed. The nurse will apply medical health benefit policy and medical management guidelines to authorize services and appropriately identify and refer requests to the Medical Director when guidelines are not met. The nurse will maintain current knowledge and understanding of the laws, regulations, and policies that pertain to the organizational unit’s business and uses clinical judgment in their application.

Job-Related Experience and Skills

• 3 or more years’ experience in a related clinical setting.

• Registered Nurse graduated from an accredited program.

• Current unrestricted PA Practical Nurse license or PA Registered Nurse license.

• Valid Driver’s License and reliable automobile transportation for on-site assignments and off-site work related activities.

Other Skills:

Competencies

• Excellent oral and written communication skills.

• Ability to identify problems and recommend solutions.

• Self-directed/Ability to work independently.

• Excellent decision making skills.

• Excellent time management skills, prioritizing work and meeting timelines.

• Ability to advocate for member/member family needs.

• Dedicated to meeting the expectations and requirements of internal and external customers.

• Obtains continuing education required to maintain professional licensure.

• Ability to achieve required performance results on all audits and Inter Rater Reliability (Peer to Peer).