Nurse Clinician RN [Cross Functional]

UBC Saint Louis , MO 63150

Posted 5 months ago

Brief Description:

The Nurse Clinician RN is responsible for reviewing escalated clinical criteria reviews for providers, members and patient client advocates within the Prior Authorization/Utilization Management department. Identify and track trends for analytics reporting to ensure clinical criteria program integrity. Maintain a professional and ethical behaviour at all times as outlined by the Nurse Practice Act and applicable company policies. To provide quality clinical criteria review for escalated Prior Authorizations as defined by Client specifications to ensure patients are serviced accurately and timely. Identifies and supports necessary updates or changes to existing clinical assessments.

Specific job duties:

  • Perform escalated clinical review and analysis of clinical program descriptions for clinical and criteria integrity.

  • Maintains contact database and responds to member and physician inquiries regarding clinical programs. Makes recommendations regarding escalation of issues, and follows through with escalation process.

  • Acts as liaison between clients, patients and patient care advocates to provide guidance on clinical criteria.

  • Performs initial clinical review and analysis of prior authorization cases based on state regulations.

  • Special projects/assignments as needed.

Supervisory Responsibility:

N/A

Desired Skills and Qualifications:

  • Nursing degree

  • 2 5 years' experience in a clinical setting

  • Registered Nursing Licensure

  • General PC knowledge including Microsoft Office, Internet and email

  • Previous clinical criteria review experience preferred

  • Active professional affiliations and/or national certification in related clinical specialty preferred

  • Able to work flexible work schedule

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Nurse Clinician RN [Cross Functional]

UBC