466 Clinical Review jobs in the United States

• Subject Matter Expertise
• Strong knowledge base in health care delivery systems, health insurance, medical care practices and trends, regulatory and accreditation agencies/standards, and provider network management.
• Strong knowledge of all Plan products and services benefits that effect clinical decision making.
• Strong knowledge of clinical nursing practice.

Our team members are the heart of what makes us better.

At Hackensack Meridian Health we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It’s also about how we support one another and how we show up for our community.

Together, we keep getting better - advancing our mission to transform healthcare and serve as a leader of positive change.

The Sleep Clinical Review Technician is responsible for clinical history, signs/symptoms, diagnosis code and test order review. Works directly with team members and ordering clinicians and their staff to educate and support appropriate documentation for coding, authorizations and appropriate testing.

This position will offer a hybrid schedule. Will be on site in Neptune/ Edison on occasion. Must also have the ability to travel to various sites within the network if needed.

1. Utilize medical necessity criteria from established medical policies and clinical practice guidelines to render precertification determinations as described in the Medical Management UM work plan. This detailed clinical judgment includes evaluating whether the requested service is a covered benefit under the member's health plan, is medically appropriate for the member's clinical condition or whether the request requires referral to a Medical Director for potential denial of the request. The Nurse Reviewer must follow each line of business' requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each request. Assists on inquiries from external parties such as the State Insurance Commissioner and from the Legal Department. Responsibilities include, but are not limited to:
   
   • Demonstrate understanding and application of over 250 Guide to Benefits, Evidence of Coverage, Plan Brochure, and Member Handbook. HMSA annually updated medical and drug policies, medical protocols, National Comprehensive Cancer Network, Milliman Care Guidelines, Drugdex, etc. to determine the medical necessity of urgent and non-urgent precertification requests. Urgent requests must be completed within 72 hours and non-urgent requests within 15 calendar days.
   • Use clinical judgment, medical necessity guidelines and plan benefits to determine approval, potential denial or alternative treatment of each urgent or non-urgent precertification request. Settings include inpatient, outpatient, in-state, out-of state and out-of country.
   • Document clinical case summary and review outcome of each review appropriately to meet regulatory and program requirements.
   • Review various types of services, including but not limited to:
   • Transplants
   • Air Ambulance
   • Chemotherapy
   • Clinical trials
   • Genetic testing
   • Cancer treatments/radiation therapy
   • Experimental/Investigational Services/Devices
   • New Technology
2. Utilize medical necessity criteria from established medical policies and clinical practice guidelines to render precertification determinations as described in the Medical Management UM work plan. This detailed clinical judgment includes evaluating whether the requested service is a covered benefit under the member's health plan, is medically appropriate for the member's clinical condition or whether the request requires referral to a Medical Director for potential denial of the request. The Nurse Reviewer must follow each line of business' requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each request. Assists on inquiries from external parties such as the State Insurance Commissioner and from the Legal Department. Responsibilities include, but are not limited to:
   
   • Call providers when additional clinical information is required to clarify or complete a complex precertification determination.
   • Approve precertification requests based on clinical judgment using criteria, medical record documentation and other information received from the provider.
   • Consult with Medical Directors on requests which do not meet clinical criteria and offer alternative covered health care options as appropriate.
   • Consult Medical Directors on potential quality issues identified during review of medical records. Refer cases to Integrated Health Management, Pharmacy Department or Benefits Integrity Department depending on the concern.
3. Evaluate suspended claims against medical records to determine the medical necessity and appropriateness of medical services, identify irregularities such as over or under-utilization of services, potential up-coding, over billing, etc.
4. Communicate timely, accurate information either verbally, electronically or in writing using clinical judgment, knowledge of medical/reimbursement policies and plan benefits to providers, members as well as internal MM staff and other internal departments (Claims Administration, Customer Relations, Provider Contracting, etc.). For denied services, ensure the denial, benefit and appeal language are accurate and consistent with department procedures, accreditation and regulatory guidelines.
5. Identify and refer members with specific medical and/or behavioral health needs or complex case management and collaborate with medical and behavioral case management staff. Identify and refer quality of care issues and suspected fraud, waste or abuse to the appropriate departments.
6. Perform pre-screening assessment of incoming pre-certification requests to ensure appropriateness of review. Advises non-clinical staff on clinical and coding questions to ensure correct system processes and entries.
7. Performs all other miscellaneous responsibilities and duties as assigned or directed.

1. Associates degree in Nursing.
2. Current, unrestricted Nursing License in the state of Hawaii as an RN or LPN.
3. Two years clinical, case management or utilization management related experience.
4. Knowledge of current standards of care to be followed for a given diagnosis and the normative values of medical tests and procedures.
5. Strong organizational skills
6. Good communication skills both verbally and written
7. Analytical skills
8. Basic knowledge of Microsoft Office applications. Including but not limited to Word, Excel, and Outlook.
9. Currently licensed in Hawaii as an RN or LPN
   
   • (if applicable upon hire, proof of licensure to be provided by employee or confirmed by Human Resources)

Position Title: Clinical Review Nurse - Concurrent Review

Work Location: Remote - California, Must either reside in CA or hold a CA license, and work hours listed

Assignment Duration: 12 months (Extension & Contract-to-hire)

Work Schedule: Training 8 am-5 pm PST - about a month-long learning journey /Work schedule 8 am-5 pm PST

Work Arrangement: Remote

Responsibilities:

o Reviews member's transfer or discharge plans to ensure a timely discharge between levels of care and facilities

o Productivity 17-20 reviews a day and quality expectations must be met

o Partners with interdepartmental teams on projects within utilization management as part of the clinical review team

o Partners and works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered

o Assesses members and/or families for post discharge needs and provide education on discharge planning options based on diagnoses, prognoses, resources, and/or preferences

o Manages and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines

o Manages and collaborates with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings

o Provides education to providers on utilization processes to ensure high quality appropriate care to members

o Partners with leadership to identify opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines

o Oversees concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care

o Provides insight and guidance on concurrent reviews to determine overall health of member, review the type of care being delivered to member, and approving treatment needs including discharge planning

o Provides guidance and expert knowledge, as appropriate, to utilization management team to address issues and validate the necessity and setting of care being delivered to the member

o Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member

o Oversees member's transfer or discharge plans to ensure a timely discharge between levels of care and facilities

o Collaborates with care management on referral of members as appropriate

o Provides subject matter expertise based on prior experience as well as training to other team members

o Manages reporting to identify trends and provides recommendations to various teams

o Performs other duties as assigned

o Complies with all policies and standards

• Top 3 must-have hard skills stack-ranked by importance