Clinical Care RN

Integrated Resources Inc.; Harrisburg (Dauphin County); On-site; USD 60,000 - 80,000; Full time

Job summary

A leading staffing firm seeks a qualified RN for a role focused on conducting service reviews for medical necessity criteria. Responsibilities include evaluating clinical information, liaising with providers, and documenting case details. Ideal for individuals with 2-3 years of experience in acute care settings.

Qualifications

• RN with 2-3 years of experience in acute care or critical care hospital.
• Professional judgment in clinical evaluations.
• Ability to collaborate with healthcare providers.

Responsibilities

• Conduct timely reviews of service requests for medical necessity criteria.
• Evaluate clinical information against plan review criteria.
• Document case information and communicate with providers.

Skills

Clinical Evaluation

Communication

Education

Associates RN Degree

Bachelor’s Degree (preferred)

Job description

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

Job Description

Position Summary:
Responsible for conducting timely reviews of all requests for services required to meet medical necessity criteria. This includes reviewing pre-certification for outpatient and inpatient services, applying criteria to inpatient admissions, performing concurrent review functions, identifying discharge planning needs, and referring members to case management.

Principal Accountabilities:

1. Evaluate clinical information submitted by providers against plan review criteria and benefit guidelines.
2. Determine if criteria for medical necessity and benefit guidelines are met using clinical information.
3. Use professional judgment to identify if additional information is needed and follow up to obtain it before making a decision.
4. Document all pertinent case information and dispositions for approvals and denials. Refer cases failing to meet interqual medical necessity criteria to the Medical Director for review and final determination.
5. Communicate with providers to initiate or coordinate outpatient services and discharge planning needs for members.
6. Act as a liaison to ensure services are provided in the least restrictive, most cost-effective, and clinically appropriate setting.
7. Collaborate with the Utilization Management Manager, Medical Director, and providers to ensure complete medical information is available for utilization management decisions.
8. Identify members who may benefit from case management services and facilitate referrals.
9. Resolve problems that could interfere with provider’s continuity and coordination of care, escalating unresolved issues to the Manager.
10. Create and maintain monthly reports on inpatient activities.
11. Perform other related duties and projects as assigned.
12. Adhere to ACFC policies and procedures.
13. Support and uphold our Mission & Values.

Qualifications

Position Qualifications/Requirements:

• Associates RN degree required; Bachelor’s degree preferred.
• RN must have 2-3 years of experience in an acute care or critical care hospital.

Additional Information

Regards,

Life Science Recruiter

Integrated Resources, Inc.

(Direct) 732-844-8721 | (W) 732-549-2030 x 311 | (F) 732-549-5549

"INC 5000’s FASTEST GROWING, PRIVATELY HELD COMPANIES" (8th Year in a Row)