Clinical Review RN PRN

Job Title

Utilization Review Nurse

Job Description

Utilizes Payer specific screening tools as a resource to assist in the determination process regarding level of service and medical necessity. Performs utilization review in accordance with all state mandated regulations. Consults with Physician Advisor to discuss medical necessity, length of stay, and appropriateness of care issues. Identify and manage concurrent and retroactive denials through communication with attending physicians, case management, multidisciplinary team, external physician resource group and payers. Completes documentation of review and denial processes in the EPIC Case Management Module. Responds to requests from the payer for all required information and treatment plans. Reviews and validates physician's orders, reports progress and unusual occurrences on patients to the payer.

Experience Required

3-5 years of recent clinical experience, preferably in area of population specialty. Experience in utilization management or review preferred. Knowledge and understanding of disease protocols and clinical pathways for commercial and government payors. Familiarity with Interqual and Millimen guidelines and regulatory mandates preferred. Strong communication (written and verbal) and critical thinking skills required. Professional and effective presentation skills required.

Education Requirements

Bachelor's degree in Nursing preferred

License/Certification Requirements

Current NJ-RN License required.

Special Requirements

Monday availability is required.

Salary Min ($)

USD $37.00

Salary Max ($)

USD $61.00