Clinical Review & Informatics Nurse Specialist

First Choice Health; United States; On-site; USD 80,000 - 100,000; Full time

Job summary

A leading healthcare organization seeks a Clinical Services & Informatics Nurse Specialist to perform utilization reviews and ensure compliance with medical policies. This fully remote role requires a Registered Nurse with significant experience in utilization review and clinical coding, offering opportunities for impactful contributions and professional development.

Qualifications

• Minimum of five years in utilization review or claims review.
• Experience in Third Party Administrator or payer-related health care industry.
• Strong understanding of clinical coding (CPT, ICD-10, HCPCS) preferred.

Responsibilities

• Perform utilization review to assess medical necessity and appropriateness of services.
• Provide training to other nurses on clinical topics and procedures.
• Collaborate with departments to resolve claims adjudication and quality of care issues.

Skills

Clinical coding

Analytical skills

Problem-solving

Negotiation

Conflict resolution

Communication skills

Education

Registered Nurse (RN) license

Tools

Electronic health records

Authorization review software

Encoder

Interqual/MCG guidelines

Job description

POSITION SUMMARY:

The Clinical Services & Informatics Nurse Specialist is primarily responsible for performing utilization review, including prior authorization and retrospective claims review, to assess for medical necessity and appropriateness of services. This role involves applying clinical expertise and judgment to ensure compliance with medical policies, InterQual guidelines, and accepted standards of care.

This role also has the opportunity to create an even deeper impact within the Medical Management Department depending on the level of expertise the applicant possesses. Ideally, the applicant would act as a resource through their knowledge of clinical coding to assist the company as a whole. With some database or software experience, this position would develop and implement enhancements to our current software (CaseTrakker) to manage the workflow for both Utilization Management and Case Management. Finally, this person would have the opportunity to assist in the ongoing training of the department’s clinical staff.

This is a fully remote position with opportunity for in person meetings with advanced notice.

EXAMPLES OF DUTIES:

1. Performs prospective, concurrent, and retrospective utilization review of clinical information to establish medical necessity, appropriateness of services, and compliance with medical policy.
2. Performs claims review to establish medical necessity and appropriateness of services in compliance with established medical policy, community standards, and Summary Plan Documents.
3. Applies clinical expertise and judgment to ensure compliance with medical policy, medical necessity guidelines, InterQual criteria, and accepted standards of care.
4. Refers cases requiring adverse determination of medical necessity to the Medical Director.
5. Identifies and refers cases for stop loss, case management, fraud/abuse and subrogation as appropriate.
6. Researches and triages clinical appeals, utilizing appropriate policies and procedures and clinical resources, to ensure timely determinations and documentation.
7. Reviews and responds to inquiries related to clinical coding, utilizing appropriate systems, policies, procedures, and external clinical and coding resources.
8. Provides clinical and coding knowledge to Medical Management and other departments as needed.
9. Utilizes analytical skills to identify problems, develop solutions, and implement courses of action within departmental policies and procedures, including recognizing trends of unusual billing, clinical practices, quality of care issues, or potential fraud and abuse.
10. Collaborates with other departments, payers, and providers to resolve claims adjudication, authorizations, quality of care, and member or provider issues.
11. Provides training to other nurses on clinical topics, processes, and procedures.
12. Maintains and updates the utilization management software to ensure accurate tracking and reporting of utilization review activities. Review and maintenance of code scripting for accuracy in a database platform.
13. Participates in policy creation and maintenance.
14. Performs other work-related duties and special projects as assigned.

QUALIFICATIONS:

• Registered Nurse (RN) with a current, unrestricted nursing license.
• Minimum of five (5) years of experience in utilization review, clinical documentation review, appeals, and/or claims review.
• Two to three years’ experience in the Third Party Administrator or payer-related health care industry.
• Familiarity of accreditation standards (ie. URAC) and the impact on all areas of an organization.
• Strong understanding of clinical coding (CPT, ICD-10, HCPCS) preferred.
• Experience using a variety of software applications including electronic health records, authorization review software, Encoder, and Interqual/MCG guidelines.
• Experience in policy creation and maintenance preferred.
• Experience in training other nurses on clinical topics and procedures preferred.
• Demonstrates analytical ability to identify problems, develop solutions, and implement a course of action within an acceptable interpretation of departmental policies and procedures.
• Excellent problem-solving, negotiation, and conflict resolution skills.
• Strong written, verbal, and interpersonal communication skills with varying levels of internal and external customers and medical professionals.
• Professional demeanor and ability to prioritize tasks with minimal direction.