Clinical Nurse Reviewer

Summary:
Support utilization management activities in compliance with State of IN contract. Clinical Nurse Reviewer will use clinical expertise for the review of medical records against appropriate criteria in conjunction with contract requirements, critical thinking, and decision-making skills to determine medical appropriateness, while maintaining production goals and QA standards. Ensures day-to-day processes are conducted in accordance with contract requirements, State policy, URAC and other regulatory standards.

Scope of Work:
Reviews and interprets patient records and compares against criteria to determine medical necessity and appropriateness of care; determines if the medical record documentation supports the need for services.
Determines approval or initiates a referral to the physician consultant and processes physician consultant decisions ensuring reason for the denial is described in sufficient detail on correspondence.
Responsible for attending training and scheduled meetings and for maintenance and use of current/updated information for review.
Maintains medical records confidentiality at all times through proper use of computer passwords, maintenance of secured files, adherence to HIPAA policies.
Utilizes proper telephone etiquette and judicious use of other verbal and written communications, following company policies, procedures, and guidelines.