Clinical Review Nurse
Job Description
Position Title: Clinical Review Nurse
PRINCIPAL RESPONSIBILITIES:
The Clinical Review Nurse is responsible for investigating and processing comprehensive and complex grievances and appeals requests from members and providers, coding justifications, and provider disputes. This position identifies through clinical review any system or processing issues that resulted in failure to provide appropriate care to members, failure to meet service expectations, billing concerns, and provider disputes. The Clinical Review Nurse has a dotted-line reporting relationship to the Chief Medical Officer.
Principal responsibilities include:
• Conducts investigations and reviews of member and provider medical necessity grievances and appeals;
• Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity;
• Extrapolates and summarizes medical information for Medical Director, consultants or other external review;
• Apply clinical medical necessity guidelines, policy, and procedures, and EOC benefit guidelines;
• Prepares recommendations to either uphold or overturn and forwards to Medical Director for approval;
• Ensures that appeals, grievances, and disputes are resolved timely to meet regulatory requirements;
• Apply expedited criteria to recommend the appropriateness of urgent requests;
• Documents and logs appeal/grievance/dispute information on relevant tracking systems;
• Generates written correspondence to providers, members and regulatory entities;
• Interact with members, providers, and/or other staff to ensure resolution of plan recommendations.
• Recognize potential quality of care concerns and refer to the Medical Director for review;
• Utilize leadership skills and serves as a subject matter expert for appeals/grievances/disputes/quality of care issues and is a resource for clinical and non-clinical team members in expediting the resolution of outstanding issues.
• Perform other duties and special projects as assigned.
ESSENTIAL FUNCTIONS OF THE JOB
• Conducts investigations and reviews of member and provider medical necessity grievances and appeals, coding justifications, and provider disputes;
• Determine the appropriateness of care provided within the context of all applicable contractual requirements, state/federal regulations, and accreditation standards;
• Identify system issues that result in failure to provide appropriate care to members or failure to meet service expectations and make recommendations for improvement;
• Perform writing, reporting, administration, and analysis; and
• Comply with the organization’s Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.
Number of Employees Supervised: 0
MINIMUM QUALIFICATIONS:
EDUCATION OR TRAINING EQUIVALENT TO:
• Active and unrestricted California Registered Nurse; and
• Bachelor's degree preferred.
MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:
• Minimum three years acute care clinical experience required;
• Minimum two years of experience in appeals and grievances casework required
• Utilization Management or Quality Management experience preferred
• Experience using standardized clinical guidelines preferred
• Milliman Care Guidelines (MCG), Managed Care and NCQA experience preferred
PRINCIPAL RESPONSIBILITIES:
The Clinical Review Nurse is responsible for investigating and processing comprehensive and complex grievances and appeals requests from members and providers, coding justifications, and provider disputes. This position identifies through clinical review any system or processing issues that resulted in failure to provide appropriate care to members, failure to meet service expectations, billing concerns, and provider disputes. The Clinical Review Nurse has a dotted-line reporting relationship to the Chief Medical Officer.
Principal responsibilities include:
• Conducts investigations and reviews of member and provider medical necessity grievances and appeals;
• Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity;
• Extrapolates and summarizes medical information for Medical Director, consultants or other external review;
• Apply clinical medical necessity guidelines, policy, and procedures, and EOC benefit guidelines;
• Prepares recommendations to either uphold or overturn and forwards to Medical Director for approval;
• Ensures that appeals, grievances, and disputes are resolved timely to meet regulatory requirements;
• Apply expedited criteria to recommend the appropriateness of urgent requests;
• Documents and logs appeal/grievance/dispute information on relevant tracking systems;
• Generates written correspondence to providers, members and regulatory entities;
• Interact with members, providers, and/or other staff to ensure resolution of plan recommendations.
• Recognize potential quality of care concerns and refer to the Medical Director for review;
• Utilize leadership skills and serves as a subject matter expert for appeals/grievances/disputes/quality of care issues and is a resource for clinical and non-clinical team members in expediting the resolution of outstanding issues.
• Perform other duties and special projects as assigned.
ESSENTIAL FUNCTIONS OF THE JOB
• Conducts investigations and reviews of member and provider medical necessity grievances and appeals, coding justifications, and provider disputes;
• Determine the appropriateness of care provided within the context of all applicable contractual requirements, state/federal regulations, and accreditation standards;
• Identify system issues that result in failure to provide appropriate care to members or failure to meet service expectations and make recommendations for improvement;
• Perform writing, reporting, administration, and analysis; and
• Comply with the organization’s Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.
Number of Employees Supervised: 0
MINIMUM QUALIFICATIONS:
EDUCATION OR TRAINING EQUIVALENT TO:
• Active and unrestricted California Registered Nurse; and
• Bachelor's degree preferred.
MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:
• Minimum three years acute care clinical experience required;
• Minimum two years of experience in appeals and grievances casework required
• Utilization Management or Quality Management experience preferred
• Experience using standardized clinical guidelines preferred
• Milliman Care Guidelines (MCG), Managed Care and NCQA experience preferred
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