Full-Time Nurse - Clinical Review

• Performs utilization review of cases to determine if the request meets medical necessity criteria.
• Facilitates resolution of escalated cases.
• Performs clinical reviews according to policies and procedures.
• Collaborates with client personnel to resolve customer concerns.
• Identifies and refers quality issues to UM Leadership.
• Assists Physician Reviewers and Medical Directors.
• Maintains written documentation.
• Ensures consistency in implementation of policy, procedure, and regulatory requirements.
• Keeps current with regulation changes.
• Adheres to all HIPAA, state, and federal regulations.
• Provides quality customer service.
• Supports teamwork, respect, diversity, and cooperation.
• Engages in phone conversations with providers and staff.
• Utilizes computer systems and software to manage cases and document reviews.
• Promotes business focus.
• Participates in the HealthHelp Quality Management Program.
• Adheres to URAC & NCQA standards.
• Prioritizes projects and meets deadlines.
• Communicates clinical concepts to providers and staff.
• Performs other related duties as assigned.

• 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 two (2) years of clinical experience
• Experience in utilization review, case management, or clinical quality improvement, preferred
• Proficient technical skills in Microsoft Office
• 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

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