Clinical Care Reviewer

Integrated Resources, Inc.; North Charleston (SC); On-site; USD 75,000 - 95,000; Full time

Job summary

A leading healthcare solutions provider is seeking a Clinical Care Reviewer to conduct comprehensive medical necessity reviews. The successful candidate will leverage clinical nursing experience to review inpatient and outpatient service requests, ensuring alignment with medical management guidelines. This role requires critical thinking, clinical judgment, and effective communication skills to navigate provider requests and promote care coordination.

Qualifications

• 3+ years’ experience in critical care or ER within an acute care environment.
• 2+ years’ experience in utilization management, preferably within managed care.

Responsibilities

• Completing medical necessity reviews under the direction of the unit Supervisor.
• Work closely with members and providers to collect information necessary for reviews.
• Evaluate requests and ensure appropriate services are approved.

Skills

Critical thinking

Clinical judgment

Communication

Tools

MS Office (Excel, Word, Outlook)

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

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 pending 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

• 3+ years’ experience in critical care or ER within an acute care environment.

• 2+ years’ experience in utilization management, preferably within managed care.

• Comfortable utilizing MS Office products, including Excel, Word, and Outlook.