The Nurse Clinician RN is responsible for reviewing escalated clinical criteria reviews for providers, members and patient client advocates within the Prior Authorization/Utilization Management department. Identify and track trends for analytics reporting to ensure clinical criteria program integrity. Maintain a professional and ethical behavior at all times as outlined by the Nurse Practice Act and applicable company policies.
In this role, you will be responsible for delivering goal-directed care to patients. Utilize assessment, planning, implementation and evaluation to provide excellent patient care in a caring and supportive environment.
In this role, you will collaborate with medical providers, nursing leadership, ancillary department leadership, nursing staff, and the clinical education department to develop and implement clinical education and evaluation to nursing and patient care staff. Facilitates evidenced-based research within a specialized area of nursing.
In this role, the selected candidate must have the ability to give and follow written and oral instructions; ability to communicate effectively with others; ability to react and perform under stress in emergency situations.
In this role, the selected candidate will coordinate and perform onsite medical record reviews at provider offices to determine appropriate coding and billing practices, compliance with quality metrics, compliance with service delivery and quality standards, and where assigned investigation of quality of care and member complaints relative to quality of care and service.
In this role, the selected candidate will provide professional nursing care to patient within assigned Specialty clinic utilizing the nursing process to assess, plan, implement and evaluate patients undergoing procedures.