Clinical Care Reviewer

Clinical Care Reviewer

A Few Words About Us Integrated Resources, Inc is a premier staffing firm recognized as one of the tri-states most well-respected professional specialty firms. IRI has built its reputation on excellent service and integrity since its inception in 1996. Our mission centers on delivering only the best quality talent, the first time and every time. We provide quality resources in four specialty areas: Information Technology (IT), Clinical Research, Rehabilitation Therapy and Nursing.

Job Description

Duration: 3 Months (Contract to Hire)

Responsibilities:

• Under 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 nurse's discretion to pending 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 unit's business and uses clinical judgment in their application.

Qualifications

Required Skills & Experience:

• Current, unrestricted SC Registered Nurse license.
• 3+ years' experience in critical care or ER within an acute care environment.
• 2+ years' experience in utilization management, preferably within managed care.
• Comfortable utilizing MS Office products, including Excel, Word, and Outlook.