Clinical Care Reviewer RN

Integrated Resources Inc.; Des Moines (IA); On-site; USD 70,000 - 90,000; Full time

Job summary

A staffing firm in Iowa seeks a Clinical Care Reviewer to perform medical necessity reviews. The role involves using clinical knowledge to assess service requests, with a focus on ensuring quality care and compliance with organizational guidelines. Ideal candidates will have extensive nursing experience and a valid Iowa RN license.

Qualifications

• Registered Nurse with 3-5 years experience in a related clinical setting.
• Valid Driver's License and reliable transportation.

Responsibilities

• Conduct thorough medical necessity reviews for inpatient and outpatient services.
• Work closely with members and providers to gather necessary information.
• Apply medical health benefit policy and medical management guidelines.

Skills

Excellent oral and written communication skills

Ability to identify problems and recommend solutions

Self-directed

Excellent time management

Advocacy for member needs

Education

Registered Nurse graduated from an accredited program

Current unrestricted Iowa Registered Nurse license

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

Job Summary

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

Experience and Skills

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

Registered Nurse

Registered Nurse graduated from an accredited program.

Current unrestricted Iowa Registered Nurse license.

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

Additional Information

Excellent oral and written communication skills.

Ability to identify problems and recommend solutions.

Self-directed/Ability to work independently.

Excellent time management skills, prioritizing work and meeting timelines.

Ability to advocate for member/member family needs.

Dedicated to meeting the expectations and requirements of internal and external customers.

Obtains continuing education required to maintain professional licensure.

Ability to achieve required performance results on all audits and Inter Rater Reliability (Peer to Peer).

Clinical Recruiter

Integrated Resources, Inc.

DIRECT # - 732 662 4717| (W) # 732-549-2030 - Ext - 311 |(F) 732-549-5549