Clinical Review Nurse

Paycor; Chicago (IL); Remote; USD 125,000 - 150,000; Full time

Job summary

An innovative healthcare company is seeking a Utilization Review Nurse to join their mission of improving healthcare quality and affordability. In this fully remote role, you will leverage your clinical expertise to perform initial reviews of medical necessity for various procedures. The ideal candidate will possess strong critical thinking skills, attention to detail, and the ability to work independently in a fast-paced environment. This position offers the opportunity to make a significant impact while collaborating with healthcare providers and enhancing patient care. If you thrive on challenges and are passionate about healthcare, this role is perfect for you.

Qualifications

• Licensed Nurse Practitioner or Registered Nurse required.
• Excellent customer service and computer skills are essential.

Responsibilities

• Perform initial clinical reviews and provide documented recommendations.
• Assist clinical staff in quality improvement projects.

Skills

Critical thinking

Attention to detail

Customer service

Computer skills

Ability to multi-task

Team collaboration

Education

Licensed Nurse Practitioner (LPN)

Registered Nurse (RN)

Tools

Clinical guidelines

Various computer programs

Job description

TurningPoint Healthcare Solutions is a rapidly growing and innovative healthcare company that supports several large national health plans to improve the quality and affordability of healthcare patients receive. We are looking for motivated individuals who want to be part of our mission and join our team!

As a Utilization Review Nurse, you will utilize your critical thinking skills, clinical expertise and judgement along with established medical criteria to perform first level clinical review for select procedures that require medical necessity authorization. We are seeking individuals who enjoy a challenge, have an ability to work independently and are capable of meeting deadlines. Previous utilization management experience is preferred. In addition to prior experience, the ideal candidate will have an extreme attention to detail, an ability to flourish in a fast-paced environment and advanced grammar, punctuation, and computer skills.This is a fully remote position with multiple shifts available!

Responsibilities

• Perform initial clinical reviews and provide documented recommendations based on the use of appropriate clinical guidelines
• Review the initial evaluation and clinical documentation against clinical standards, applicable state regulations and relevant treatment guidelines
• Assist clinical staff in quality improvement projects to provide instructive feedback to clients and providers within scope of practice
• Resolve patient care issues by working one-on-one with community providers and staff to resolve issues in the determination process
• Provide information by responding to queries of physicians and their practice staff, sorting and distributing messages and documents, and preparing information for determinations
• Improve quality results by studying, evaluating procedures and processes and recommending changes, if needed
• Serves and protects the company by adhering to accreditation standards, professional standards, company policies and procedures, federal, state, and local requirements, and professional and licensing standards

Qualifications:

• Licensed Nurse Practitioner (LPN) or Registered Nurse (RN) required
• Comprehensive knowledge of general nursing theory and practices
• Excellent customer service skills and phone etiquette
• Proficient computer skills, including typing and an ability to maneuver through various programs
• Previous Utilization Management experience preferred but not required
• Knowledge of musculoskeletal surgical procedures, cardiac procedures, pain management and/ or wound care is a plus
• Ability to multi-task and manage tasks to completion on a timely basis and in an organized fashion
• Ability to work collaboratively as part of a team