Medix
Clinical Review Nurse
Medix, New York, New York, us, 10261
Position Summary:
This role involves reviewing service requests from providers, determining medical necessity based on evidence-based criteria, providing authorization for services, and managing day-to-day operations. The Clinical Review Nurse acts as a liaison between participants and providers, ensuring compliance with regulatory and contractual requirements.
Key Responsibilities:Review and process service authorization requests from in-network providers.Communicate decisions made by the Interdisciplinary Team (IDT) in a timely manner.Collect, evaluate, and analyze information to make prospective, concurrent, and retrospective decisions using evidence-based criteria.Suggest alternate care plans and collaborate with the Provider/IDT for appropriate service utilization.Document case reviews, communications, and outcomes in the electronic case file.Present cases to the site Physician and/or Medical Director for review and determination.Ensure medical reviews meet standards for decision turnaround times.Participate in inter-rater reliability testing on medical necessity criteria application.Identify and report potential quality of care concerns to Quality Management.Maintain confidentiality in compliance with State and Federal Law and CenterLight Healthcare policies.Identify and communicate system improvements or issues affecting care or service requirements.Ability to travel between clinic locations to perform duties.Perform other duties as assigned.Requirements:
Education:
BSN required.
Experience:
3-5 years of clinical experience in a hospital or home care setting.Knowledge of Medicare and Medicaid guidelines.Experience in case management, discharge planning, and utilization review at a Managed Care Organization (2-3 years preferred).Skills:
Proficiency in Microsoft Office and Excel.Strong verbal and written communication skills.Excellent problem-solving, analytical, and organizational skills.Ability to manage multiple projects and adapt to changing needs.Willingness to travel to various locations as needed.Schedule:
Monday to Friday, 8:30 AM - 5:30 PM (40 hours per week).
This position offers an opportunity to apply clinical expertise in a managed care environment, ensuring that participants receive appropriate and necessary care while adhering to regulatory standards.
Medix is acting as an Employment Business in relation to this vacancy.
This role involves reviewing service requests from providers, determining medical necessity based on evidence-based criteria, providing authorization for services, and managing day-to-day operations. The Clinical Review Nurse acts as a liaison between participants and providers, ensuring compliance with regulatory and contractual requirements.
Key Responsibilities:Review and process service authorization requests from in-network providers.Communicate decisions made by the Interdisciplinary Team (IDT) in a timely manner.Collect, evaluate, and analyze information to make prospective, concurrent, and retrospective decisions using evidence-based criteria.Suggest alternate care plans and collaborate with the Provider/IDT for appropriate service utilization.Document case reviews, communications, and outcomes in the electronic case file.Present cases to the site Physician and/or Medical Director for review and determination.Ensure medical reviews meet standards for decision turnaround times.Participate in inter-rater reliability testing on medical necessity criteria application.Identify and report potential quality of care concerns to Quality Management.Maintain confidentiality in compliance with State and Federal Law and CenterLight Healthcare policies.Identify and communicate system improvements or issues affecting care or service requirements.Ability to travel between clinic locations to perform duties.Perform other duties as assigned.Requirements:
Education:
BSN required.
Experience:
3-5 years of clinical experience in a hospital or home care setting.Knowledge of Medicare and Medicaid guidelines.Experience in case management, discharge planning, and utilization review at a Managed Care Organization (2-3 years preferred).Skills:
Proficiency in Microsoft Office and Excel.Strong verbal and written communication skills.Excellent problem-solving, analytical, and organizational skills.Ability to manage multiple projects and adapt to changing needs.Willingness to travel to various locations as needed.Schedule:
Monday to Friday, 8:30 AM - 5:30 PM (40 hours per week).
This position offers an opportunity to apply clinical expertise in a managed care environment, ensuring that participants receive appropriate and necessary care while adhering to regulatory standards.
Medix is acting as an Employment Business in relation to this vacancy.