Job: Initial Clinical Review Nurse

The Initial Clinical Review Nurse is responsible for ensuring that UM policies and procedures are followed during the applicable review process. Processes member or provider service request to determine in accordance with the benefit plan the clinical criteria required for approval using clinical decision support tools.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties maybe assigned.

Responsible for ensuring that UM policies and procedures are followed during the review process.

Uses Medicaid Coverage Guideline and Interqual Decision Support criteria for making utilization review decisions.

Initial Clinical Review Nurse may be asked to assist in the non-certifications

Maintains all content and notification process for timeframe requirements for organizational determinations according to CMS, OIR, ACHA and URAC standards.

Provide advice and consultation to non clinical staff on problem issues.

Meet response standards of precertification requests to maintain the highest level of service.

Conducts precertification activities and provide a daily production report to the Associate Medical Director.

Initial Clinical Review Nurse does not issue non-certifications, but refers all such questions and concerns to Medical Director or Associate Medical Director in a timely manner.

Assist in the Orient of new employees by providing training and feedback.

Serves as a resource to non-clinical staff in processing work and departmental workflows.

Reports monthly utilization review activity as directed by Director of Nursing.

Identify and report network gaps and provider issues to provider Operations Department.

Protects and secures all identifiable personal health information according to HIPPA requirements.

Maintains high degree of confidentiality on all patient information.

Performs other duties as assigned.

SUPERVISORY RESPONSIBILITIES

Acts as clinical resource for non-clinical staff

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/ or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Excellent written and oral communication organizational skills
Computer literate

EDUCATION and/or EXPERIENCE

3 years minimum clinical experience

3 years minimum managed care/ UR experience preferred

CERTIFICATES, LICENSES, REGISTRATIONS

Requires Active and unrestricted Florida Nursing License LPN/RN