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TurningPoint Healthcare Solutions is a rapidly growing healthcare company supporting large national health plans to improve quality and affordability of patient care. As a Clinical Review Nurse (Utilization Review Nurse), you will perform first-level clinical reviews for select procedures requiring medical necessity authorization. You will apply critical thinking, clinical expertise, and established medical criteria to evaluate cases and provide documented recommendations.
Key responsibilities include:
- Perform initial clinical reviews and provide documented recommendations based on appropriate clinical guidelines
- Review initial evaluations and clinical documentation against clinical standards, applicable state regulations, and relevant treatment guidelines
- Assist clinical staff in quality improvement projects, providing 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 determination process issues
- Respond to physician and practice staff queries, sort and distribute messages and documents, and prepare information for determinations
- Study, evaluate procedures and processes, and recommend improvements as needed
- Adhere to accreditation standards, professional standards, company policies, federal/state/local requirements, and professional licensing standards
The ideal candidate enjoys challenges, works independently, meets deadlines, has extreme attention to detail, thrives in fast-paced environments, and possesses advanced grammar, punctuation, and computer skills.
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 ability to navigate 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 in an organized fashion
- Ability to work collaboratively as part of a team
