Clinical Review Nurse

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

Job summary

TurningPoint Healthcare Solutions is seeking an Utilization Review Nurse to apply clinical guidelines for medical necessity and contribute to a fast-paced environment. You will evaluate documentation, coordinate with providers, and support quality improvement initiatives while maintaining high attention to detail.

The role emphasizes independent work, strong communication with physicians, and adherence to regulatory standards in a healthcare setting.

Qualifications

• Licensed RN or NP required with knowledge of general nursing theory.
• Experience with utilization management preferred but not required.
• Strong customer service and phone etiquette; able to work independently.
• Proficient computer skills and typing; able to navigate multiple programs.
• Detail-oriented, organized, and able to meet deadlines in a fast-paced environment.

Responsibilities

• Perform initial clinical reviews and provide documented recommendations based on clinical guidelines.
• Review the initial evaluation against clinical standards, state regulations and guidelines.
• Assist clinical staff in quality improvement projects within scope of practice.
• Resolve patient care issues by coordinating with community providers and staff.
• Respond to physician queries and prepare information for determinations.
• Improve quality by evaluating procedures and recommending changes when needed.
• Adhere to accreditation, professional standards, and company policies and licensing requirements.

Skills

Nursing service

Customer service

Phone etiquette

Computer skills

Utilization Management experience

Multi-tasking

Teamwork

Education

RN or NP license

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.

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