Clinical Review Nurse (Hybrid)

Job Description

Clinical Review Nurse - RN or LPN (Hybrid)

Compensation and Benefits

Salary:

• LPN/LVN: $80,000 - $85,000
• RN: $107,000 - $115,000
• Comprehensive Benefits

Location: New York, NY

Organization: Wonderful health plan organization

Position Summary
Reports to Team Lead, Clinical Quality and Record Review. Works independently and with other departments and/or vendors to ensure clinical potential quality issues are tracked, investigated and resolved in accordance with TRICARE and Plan requirements. Primarily responsible for conducting post-service in-depth clinical reviews (all care settings) in accordance with accepted standards of care. The overall goal is to improve clinical service delivery.

Responsibilities

Key Duties:

• Utilizes clinical expertise to conduct clinical case retrospective reviews to determine deviation from standard of care or gaps in care and presence of mandatory data elements. Document progress of investigation and findings in internal databases and/or Excel spreadsheets.
• Conduct chart reviews and audits both electronic and at medical facilities and providers' offices.
• Write succinct and targeted investigative summaries. Write quality review determination letters.
• Participate in collection and analysis of data for clinical CDRLs reports (i.e., monthly quality issue report, AHRQ PSI report, annual clinical quality management program report).
• Participate in continuous quality improvement activities/root cause analysis to resolve identified quality issues and ensure forward movement in beneficiary service delivery.

Qualifications

Education:

• BA, BS, or BSN preferred

Licenses and Certification:

• Current and unrestricted state RN or LPN/LVN license required (CT, NJ, NY, PA). You can get it after you start and company will pay the fees

Skills:

• Five years of healthcare quality management experience.
• Abstractor experience required
• Five years of clinical nursing experience.
• Quality assurance/improvement experience in a managed health plan, integrated health care system, or health care accreditation or regulatory agency.
• Manages assigned caseload in accordance with established performance metrics.

About Us
RCM Healthcare Services' mission is to provide opportunities for qualified candidates across medical professions. We deliver timely results and have built a reputation of trust with our clients and candidates. Since 1975, we have been providing staffing solutions to many of the finest healthcare institutions across the nation and careers for thousands of candidates. As professional career opportunity matchmakers, we follow up and follow through to help our clients and candidates reach their career and life goals. We proudly hold the Joint Commission Gold Seal of Approval as well.



Equal Employment Opportunity & Reasonable Accommodation RCM Technologies is an equal opportunity employer and values diversity. We are committed to providing reasonable accommodations to qualified individuals with disabilities in accordance with the Americans with Disabilities Act (ADA) and applicable state laws. If you require a reasonable accommodation to apply for or perform this role, please contact us and we will engage in an interactive process to support your needs.


#AC1
#ACP