RN - Clinical Care Reviewer UM

divh2RN - Clinical Care Reviewer UM/h2pIntegrated Resources, Inc., is led by a seasoned team with combined decades in the industry. We deliver strategic workforce solutions that help you manage your talent and business more efficiently and effectively. Since launching in 1996, IRI has attracted, assembled and retained key employees who are experts in their fields. This has helped us expand into new sectors and steadily grow./ph3Job Description/h3pJob Summary/ppThe primary purpose of the job is to:/ppUnder 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 nurses 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 units business and uses clinical judgment in their application./ppJob-Related Experience and Skills/pulli3 or more years experience in a related clinical setting./liliRegistered Nurse graduated from an accredited program./liliCurrent unrestricted PA Practical Nurse license or PA Registered Nurse license./liliValid Drivers License and reliable automobile transportation for on-site assignments and off-site work related activities./li/ulpOther Skills:/ppCompetencies/pulliExcellent oral and written communication skills./liliAbility to identify problems and recommend solutions./liliSelf-directed/Ability to work independently./liliExcellent decision making skills./liliExcellent time management skills, prioritizing work and meeting timelines./liliAbility to advocate for member/member family needs./liliDedicated to meeting the expectations and requirements of internal and external customers./liliObtains continuing education required to maintain professional licensure./liliAbility to achieve required performance results on all audits and Inter Rater Reliability (Peer to Peer)./li/ulh3Qualifications/h3pPhysical Effort/Working Conditions/pulliReasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the job./liliPrimarily works in a climate controlled office based setting. May require driving or commuting to health care facilities. Some positions may require a large amount of walking within the health care facility./li/ulh3Additional Information/h3pFeel free to forward my email to your friends/colleagues who might be available. We do offer referral Bonus./p/div

Careers Integrated Resources Inc