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.
Desired Skills and Qualifications:
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