Care Review Clinician

Integrated Resources Inc.; Columbus (OH); On-site; USD 70,000 - 90,000; Full time

Job summary

A leading company in healthcare solutions is seeking a Utilization Review Nurse. In this role, you will focus on reviewing inpatient cases and ensuring optimal outcomes for healthcare members. Requires active RN license, extensive hospital experience, and a background in utilization management. Join a committed team that values your expertise in delivering the right care at the right time.

Qualifications

• Minimum 3-4 years of clinical practice in hospital setting.
• 1+ year of experience in utilization management or case management.
• Familiarity with Millemen and Interqual is a plus.

Responsibilities

• Review inpatient cases for medical necessity and utilization management.
• Provide prior authorizations and concurrent reviews.
• Ensure compliance with state and federal regulations.

Skills

Utilization Review

Clinical Practice

Clerical Experience

Insurance Knowledge

Education

Active State Nursing (RN) License

Job description

Integrated Resources, Inc., is led by a seasoned team with combined decades in the industry. We deliver strategic workforce solutions that help you manage your talent and business more efficiently and effectively. Since launching in 1996, IRI has attracted, assembled and retained key employees who are experts in their fields. This has helped us expand into new sectors and steadily grow.

We’ve stayed true to our focus of finding qualified and experienced professionals in our specialty areas. Our partner-employers know that they can rely on us to find the right match between their needs and the abilities of our top-tier candidates. By continually exceeding their expectations, we have built successful ongoing partnerships that help us stay true to our commitments of performance and integrity.

Our team works hard to deliver a tailored approach for each and every client, critical in matching the right employers with the right candidates. We forge partnerships that are meant for the long term and align skills and cultures. At IRI, we know that our success is directly tied to our clients’ success.

Job Description

Works with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and other utilization management activities aimed at providing Healthcare members with the right care at the right place at the right time. Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review. Assesses services for Members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines. Duties: Review cases for in patients/in hospital: skilled care, acute rehab and long term acute care Nurses working at the facilities Members are being care for, will be sending over clinical information to be reviewed by the Care Review Clinician. Therefore, this agent will not be traveling and will be reviewing information at the office.

Qualifications

• Utilization Review in hospital setting .
• Prior author experience .
• Inpatient hospital experience .
• Nurses who are used to doing both production and review work .
• RN required .
• Millemen is a MUST .
• Interqual is PLUS .
• Good clerical experience .
• Insurance experience PLUS .
• Required Experience: Minimum 3-4 years of clinical practice in hospital setting.
• 1+ year utilization management, and/or case management.
• Required Licensure/Certification: Active, unrestricted State Nursing (RN) license in good standing.

Additional Information

All your information will be kept confidential according to EEO guidelines.