Full-Time Nurse - Clinical Review

Performs utilization review of cases to determine medical necessity based on client and governing body policies. Resolves escalated cases requiring special handling. Conducts clinical reviews following HealthHelp policies and procedures within state/federal/client timelines.

Collaborates with client personnel to address customer concerns. Identifies and refers quality issues to UM Leadership. Assists Physician Reviewers and Medical Directors ensuring compliance with review timeframes.

Maintains accurate documentation per HealthHelp policy. Ensures consistent policy, procedure, and regulatory implementation in collaboration with Nursing Management. Stays updated on regulatory changes from Compliance and Nursing Management.

Adheres to HIPAA, state, and federal regulations related to clinical programs. Provides quality customer service to providers, administrative staff, and others. Creates a supportive environment fostering teamwork, respect, diversity, and cooperation.

Engages in phone conversations with providers, members, internal staff, PCPs, and rendering providers for appropriate care decisions. Effectively uses computer systems to manage cases and document reviews.

Demonstrates business focus, understanding the company's vision, mission, and strategy. Participates in Quality Management, as needed. Adheres to URAC & NCQA standards.

Prioritizes projects, works independently under pressure, and meets deadlines. Communicates clinical concepts to providers and staff. Performs other related duties as assigned.

Requirements:

• RN, LPN/LVN graduate from accredited school
• Current, active, unrestricted RN, LPN/LVN license in U.S.
• Minimum 2 years clinical or administrative experience
• Experience in utilization review, case management, or clinical quality improvement (preferred)
• Proficient in Microsoft Office (Word, Excel, PowerPoint) and adaptable to healthcare software
• Experience with state/federal regulatory and compliance standards (preferred)
• Working knowledge of NCD and LCD
• Knowledge of insurance terminology
• Strong organizational and time management skills
• Excellent written and verbal communication skills
• Critical thinking abilities
• Highly motivated, self-starter, and team player

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