Clinical Care Reviewer

Integrated Resources Inc.; Des Moines (IA); On-site; USD 60,000 - 80,000; Full time

Job summary

Integrated Resources, Inc. is seeking a Clinical Care Reviewer to perform medical necessity reviews as directed by the unit Supervisor. The role involves using clinical knowledge to evaluate service requests and ensure compliance with medical management guidelines. This position requires a Registered Nurse with 3-5 years of clinical experience, offering a vital opportunity to contribute to care quality and service approval processes.

Qualifications

• 3-5 years of experience in a clinical setting.
• Registered Nurse graduated from an accredited program.
• Valid Driver’s License and reliable transportation.

Responsibilities

• Conduct medical necessity reviews for inpatient and outpatient services.
• Collaborate with providers to collect necessary information.
• Evaluate requests to ensure appropriate services are approved.

Skills

Clinical judgment

Communication

Attention to detail

Education

Registered Nurse

Job description

Integrated Resources, Inc is a premier staffing firm recognized as one of the tri-states most well-respected professional specialty firms. IRI has built its reputation on excellent service and integrity since its inception in 1996. Our mission centers on delivering only the best quality talent, the first time and every time. We provide quality resources in four specialty areas: Information Technology (IT), Clinical Research, Rehabilitation Therapy and Nursing.

Job Description

Under the direction of the unit Supervisor, the Clinical Care Reviewer is responsible for completing medical necessity reviews. Using clinical knowledge and nursing experience, the nurse reviews provider requests for inpatient and outpatient services, working closely with members and providers to collect all information necessary to perform a thorough medical necessity review. It is within the nurse’s discretion to send requests for additional information and/or request clarification. The nurse will use his/her professional judgment to evaluate the request to ensure that appropriate services are approved and recognize care coordination opportunities and refer those cases as needed. The nurse will apply medical health benefit policy and medical management guidelines to authorize services and appropriately identify and refer requests to the Medical Director when guidelines are not met. The nurse will maintain current knowledge and understanding of the laws, regulations, and policies that pertain to the organizational unit’s business and uses clinical judgment in their application.

Qualifications

• Three to five years - 3 or more years’ experience in a related clinical setting.

• Registered Nurse graduated from an accredited program.

• Valid Driver’s License and reliable automobile transportation for on-site assignments and off-site work related activities.