CLINICAL REVIEWER-RN Details

CLINICAL REVIEWER-RN

Cooper University Health Care - Camden, NJ

Employment Type : Full-Time

Short Description


Utilizes Payer specific screening tools as a resource to assist in the determination process regarding level of service and medical necessity.
Performs utilization review in accordance with all state mandated regulations.
Consults with Physician Advisor to discuss medical necessity, length of stay, and appropriateness of care issues.
Identify and manage concurrent and retroactive denials through communication with attending physicians, case management, multidisciplinary team, external physician resource group and payers.
Completes documentation of review and denial processes in the EPIC Case Management Module.
Responds to requests from the payer for all required information and treatment plans.
Reviews and validates physician’s orders, reports progress and unusual occurrences on patients to the payer.

Special Requirements
MINIMUM QUALIFICATIONS
Education:
Bachelor’s degree in Nursing preferred

Experience:
3-5 years of recent clinical experience, preferably in area of population specialty.
Experience in utilization management or review preferred.
Knowledge and understanding of disease protocols and clinical pathways for commercial and government payors. Familiarity with Interqual and Millimen guidelines and regulatory mandates preferred.
Strong communication (written and verbal) and critical thinking skills required. Professional and effective presentation skills required.

Required License/Certifications/ Registration:
Current NJ-RN License required.
MINIMUM QUALIFICATIONS (Continued)
Other Qualifications:
Effective problem-solving skills, including the ability to analyze complex situations, draw conclusions and implement actions appropriately and efficiently.
Scheduled Days / Hours: weekdays, day shift.
Full Time
Day