RN Clinical Review Nurse - Mitchell Martin : Job Details

A Day treatment facility located in Flushing, NY is looking for an RN Clinical Review Nurse. Position Type: Contract/Hybrid (In office/remote work) Schedule: Mon-Fri 8:30am-5:30pm (1 Hour Lunch) Location: Uniondale, NY JOB PURPOSE: • The Clinical Review Nurse is responsible for complying with the day-to-day operations of the Clinical Review Department. • Responsibilities include reviewing, recommending and providing authorization for services requested by providers based on evidence-based medical necessity criteria. • The Senior Director of Clinical Review will monitor the Clinical Review Nurse's activities and outcomes, ensuring compliance with established regulatory and contractual requirements. • The position will serve as a liaison between Client and its participants and providers. JOB RESPONSIBILITIES: • Processes requests for authorization from in-network providers and communicates in a timely manner when the decision has been made by the Interdisciplinary Team (IDT). • Collects, reviews, and evaluates information necessary to reach prospective, concurrent and retrospective decisions using objective evidence-based clinical criteria. • Suggests alternate care plans, makes recommendations and coordinates with the Provider/IDT for appropriate utilization of services. • Documents case reviews, associated communications, and outcomes in the electronic case file. • Presents cases to the site Physician and/or Medical Director for review and determination. • Works closely with the Physician and/or Medical Director to ensure that medical review of specific cases occurs timely and meets standards for decision turnaround times. • Participates in periodic inter-rater reliability testing on medical necessity criteria application. • Recognizes and refers potential quality of care concerns to Quality Management. • Maintains confidentiality of all information in compliance with State and Federal Law and Client policy. • Identifies and communicates system improvements or individual care issues that would cause failure to provide appropriate care or meet service requirements. • Performs other duties as assigned. QUALIFICATIONS: Education: • BSN required Experience: • Minimum of three to five (3 - 5+) years' experience in a hospital or home care clinical setting. • Knowledgeable about Medicare and Medicaid guidelines. • Case Management and discharge planning experience is beneficial. • Two to three (2 - 3) years of Utilization Review experience at a Managed Care Organization is preferred. Other: • Proficient in computer programs such as Microsoft Office and Microsoft Excel a plus. • Excellent verbal and written communication skills. • Excellent problem solving and analytical skills. • Accurate attention to detail with strong organizational skills. • Demonstrated ability to manage multiple projects and be flexible. • Able to travel to any of the CLHC locations, as needed. Please email: [email protected] #LI-JA1