Clinical Review Nurse

TurningPoint Healthcare Solutions; Florida; On-site; USD 65,000 - 85,000; Full time

Job summary

TurningPoint Healthcare Solutions is seeking a Utilization Review Nurse to perform first-level clinical reviews using established medical criteria for authorization decisions. The role requires independent work, attention to detail, and the ability to meet deadlines in a fast-paced healthcare environment.

Ideal candidates are licensed RNs or LPNs with strong nursing knowledge, excellent communication, and proficient computer skills to navigate multiple programs.

Qualifications

• Licensed RN or LPN required.
• Strong nursing theory knowledge.
• Excellent customer service and phone etiquette.
• Proficient computer skills and ability to navigate various programs.
• Prior utilization management experience preferred but not required.
• Knowledge of musculoskeletal, cardiac, pain management or wound care is a plus.
• Ability to multi-task and meet deadlines in a fast-paced environment.”

Responsibilities

• Perform initial clinical reviews and provide documented recommendations based on appropriate clinical guidelines.
• Review initial evaluation and clinical documentation against clinical standards, state regulations and treatment guidelines.
• Assist clinical staff in quality improvement projects with feedback to clients and providers within scope of practice.
• Resolve patient care issues by working with community providers and staff to finalize determinations.
• Respond to queries from physicians and practice staff; sort and distribute messages and documents.
• Improve quality by evaluating procedures and recommending changes.
• Adhere to accreditation standards, professional standards, company policies and regulatory requirements.

Skills

Nursing knowledge

Customer service

Communication

Computer skills

Multitasking

Teamwork

Education

Registered Nurse (RN)

Licensed Practical Nurse (LPN)

Job description

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.

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

Requirements

• 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