Clinical Review Nurse
Less than 5 years experience • Managed Care & Health Insurance
Works with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and otherutilization management activities aimed at providing Healthcare members with the right care at the right place at the right time. Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review. Assesses services for Members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines
Duties: Review cases for in patients/in hospital: skilled care, acute rehab and long term acute care
Nurses working at the facilities Members are being care for, will be sending over clinical information to be reviewed by the Care Review Clinician. Therefore, this agent will not be traveling and will be reviewing information at the office.
Hospital Utilization Management. Insurance Utilization Manager/Review and Millemen Experience (MCG). No case managers if that is their only experience. Must have Utilization Review or Management. Utilization Review (1 year +), Past hospital experience (3-4 years of experience, less experience is ok if they have more Utilization Review experience)
Potential for longer term dependent on enrollment
Workers will be doing Concurrent Inpatient Review
MUST have one of the following AT LEAST
-Utilization Review in hospital setting
Nurses who are used to doing both production and review work
=Millemen is a MUST
-Interqual is PLUS
-MUST have 3+ years solid experience inpatient/hospital/prior author, NO new grads or less than 3 years of experience
Major Plus: HOSPITAL experience - they are quicker to train, pick up the job duties quickly, and tend to stay in the position longer so this is NUMBER ONE on qualifications.
Some kind of clinical decision making in time sensitive environment is necessary for success!!!