Care Review Nurse

Integrated Resources Inc.; Columbus (OH); On-site; USD 55,000 - 75,000; Full time

Job summary

A leading company in healthcare services is seeking a Care Review Clinician for their Medicaid Division. The candidate will play a crucial role in inpatient medical necessity reviews, ensuring the best outcomes for members while adhering to regulatory guidelines. Ideal individuals must have relevant Utilization Review experience and a strong clinical assessment background.

Qualifications

• 1+ year of Utilization Review experience or 3-4 years of recent hospital experience.
• Experience with MCG guidelines is a plus.
• Nurses with production and review work experience are welcomed.

Responsibilities

• Review inpatient cases for medical necessity and authorization.
• Conduct concurrent reviews based on clinical information provided.

Skills

Hospital Utilization Management

Utilization Review

Clinical Evaluation

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, which is 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 requiring hospitalization and/or procedures, providing prior authorizations and/or concurrent review. Assesses services for Members to ensure optimal outcomes, cost-effectiveness, and compliance with all state and federal regulations and guidelines.

Division

Medicaid Division

Responsibilities

• Review cases for inpatient/hospital care: skilled care, acute rehab, and long-term acute care.
• Clinical information will be sent by nurses at the facilities where members are being cared for, for review by the Care Review Clinician. This role does not require travel and involves reviewing information at the office.

Qualifications

Background

• Experience in Hospital Utilization Management and Insurance Utilization Review/Millemen experience (MCG). No case managers if that is their only experience.
• Must have Utilization Review experience (1+ years) or recent hospital experience (3-4 years), with more weight given to Utilization Review experience.
• Potential for long-term employment depending on enrollment.
• Role involves performing Concurrent Inpatient Review.
• Must have at least one of the following:
• Utilization Review in a hospital setting.
• Nurses experienced in both production and review work.

Additional Information

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