Clinical Care Reviewer UM (RN/LPN)

Clinical Care Reviewer UM (RN/LPN)

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+ (Possible Extension)

Our client is looking to hire Clinical Care Reviewer UM.

Job description:

• The primary purpose of the job is to:

• 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 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 unit's business and uses clinical judgment in their application.

Job-Related Experience and Skills:

• Registered Nurse graduated from an accredited program.

• Current unrestricted Iowa Registered Nurse license or LPN

• Valid Driver's License and reliable automobile transportation for on-site assignments and off-site work related activities.

Physical Effort/Working Conditions

• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the job.

• Primarily 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

Qualifications

• 3 or more years' experience in a related clinical setting.

• Registered Nurse or LPN

• Excellent oral and written communication skills.

• Ability to identify problems and recommend solutions.

• Self-directed/Ability to work independently.

• Excellent decision making skills.

• Excellent time management skills, prioritizing work and meeting timelines.

• Ability to advocate for member/member family needs.

• Dedicated to meeting the expectations and requirements of internal and external customers.

• Obtains continuing education required to maintain professional licensure.

• Ability to achieve required performance results on all audits and Inter Rater Reliability (Peer to Peer).

Careers Integrated Resources Inc