Clinical Review Nurse
4 weeks ago
The Clinical Review Nurse position is a critical role in assessing the medical appropriateness of proposed treatments and medications for our injured employees. This position partners with the Client Claims Adjuster team to expedite medically necessary treatment for each claim, while maintaining a solid understanding of the Client's mission, vision, and values.
Key Responsibilities- Review treatment authorization requests based on state guidelines and medical necessity, and make decisions to approve or deny.
- Work with Claims adjusters on denial decisions to ensure the denial doesn't adversely affect the claim outcome.
- Perform Utilization Review activities prospectively, concurrently, or retrospectively in accordance with jurisdictional and evidence-based guidelines.
- Use clinical/nursing skills to determine whether all aspects of a patient's care are medically necessary and appropriately delivered.
- Communicate effectively with claims adjusters, clients, vendors, supervisors, and other parties to coordinate appropriate medical care and return to work.
- Perform clinical assessments via information in medical/pharmacy reports and case files, and assess client's situation to include psycho-social needs, cultural implications, and support systems in place.
- Objectively and critically assess all information related to the current treatment plan to identify barriers, clarify, or determine realistic goals and objectives, and seek potential alternatives.
- Partner with adjusters to develop medical resolution strategies to achieve maximal medical improvement or the appropriate outcome.
- Evaluate and update treatment and return to work plans within established protocols throughout the life of the claim.
- Engage specialty resources as needed to achieve optimal resolution.
- Bachelor's degree in nursing (BSN)
- Active unrestricted RN license that can be validated thru PRC website
- 1-2 years of relevant Clinical experience in any medical/surgical department, Orthopedic, Medical/Surgical ICU, Coronary Care Unit (CCU), Rehabilitation, Emergency department
- Written and verbal fluency in English
- Candidate should be willing to work onsite (BGC)
- Candidate should be willing to work in US operation hours
- Proficiency in all Microsoft Office products including Project, Word, Excel, PowerPoint, Visio, and SharePoint
- Knowledge of workers' compensation laws and regulations, behavioral health, case management practice, URAC standards, ODG, Utilization review, pharmaceuticals to treat pain, pain management process, drug rehabilitation, state workers compensation guidelines, periods of disability, and treatment needed
- Leadership/management/motivational skills as well as analytic and strong organizational skills
- Ability to work in a team environment and to meet or exceed Performance Competencies
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