RN/LPN Clinical Care Reviewer - Contract to Hire

Zolontech; Philadelphia (Philadelphia County); On-site; USD 70,000 - 90,000; Full time

Job summary

Zolontech is seeking an RN/LPN Clinical Care Reviewer in Philadelphia, PA. This role is contract-to-hire, requiring 3+ years of critical care experience and a current PA nursing license.

The Clinical Care Reviewer will evaluate medical necessity reviews, apply clinical judgment, and ensure appropriate services are approved based on benefit policies. Strong proficiency in MS Office is also required.

This opportunity offers a chance to work with a leading firm serving federal clients in IT and healthcare sectors.

Qualifications

• Current, unrestricted PA Registered Nurse/LPN license.
• 3+ years' experience in critical care or ER within an acute care environment.
• 2+ years' experience in utilization management, preferably within managed care.

Responsibilities

• Complete medical necessity reviews under Supervisory direction.
• Evaluate requests for inpatient and outpatient services.
• Maintain knowledge of laws and regulations relevant to the role.

Skills

Critical care experience

Utilization management

MS Office proficiency

Education

Current PA Registered Nurse/LPN license

Tools

Excel

Word

Outlook

Job description

RN/LPN Clinical Care Reviewer - Contract to Hire

Zolon Tech, Inc. (ZTI) is one of the top small disadvantaged businesses serving federal clients with ISO 9001:2008, ISO/IEC 20000:2005 and SEI rated CMMI ML3 credentials. Zolon’s core offerings include IT Strategic Services, Data Services, and Enterprise Application Services, Application Life Cycle Support, Systems Engineering and MSP-VMS staffing services.

Cloud Services, IT Strategic Services, System Engineering, IT Security, Gov 2.0 Solutions

Title : RN/LPN Clinical Care Reviewer

Job Type : Contract to Hire

Contract : 3 months

Location : Philadelphia, PA 19113

Responsibilities

Under the direction of the unit Supervisor, the Clinical Care Reviewer is responsible for completing medical necessity reviews. Using clinical knowledge and nursing experience, the nurse reviews provider requests for inpatient and outpatient services, working closely with members and providers to collect all information necessary to perform a thorough medical necessity review. It is within the nurse's discretion to pending requests for additional information and/or request clarification. The nurse will use his/her professional judgment to evaluate the request to ensure that appropriate services are approved and recognize care coordination opportunities and refer those cases as needed. The nurse will apply medical health benefit policy and medical management guidelines to authorize services and appropriately identify and refer requests to the Medical Director when guidelines are not met. The nurse will maintain current knowledge and understanding of the laws, regulations, and policies that pertain to the organizational unit’s business and uses clinical judgment in their application.

Qualifications

• Current, unrestricted PA Registered Nurse/LPN license.
• 3+ years' experience in critical care or ER within an acute care environment.
• 2+ years' experience in utilization management, preferably within managed care.
• Comfortable utilizing MS Office products, including Excel, Word, and Outlook.

All your information will be kept confidential according to EEO guidelines.