Clinical Review Registered Nurse

TekWissen is a global workforce management provider headquartered in Ann Arbor, Michigan that offers strategic talent solutions to our clients world-wide. Our client is a health insurance company. It offers different types of health care coverage plans that include individual and family, dental and vision, plans for employers, etc.

Title: Clinical Review Registered Nurse Work Location: Vermont Duration: 1-3 Months Job Type: Contract Work Type: Remote POSITION SUMMARY: This position executes utilization management processes to ensure the delivery of medically necessary and appropriate, cost-effective and high-quality care through the performance of clinical reviews. Reviews requests against standardized medical necessity and appropriateness criteria for an initial and a continued service authorization. Identifies questionable cases and refers to superior or a medical director for review.

Conduct clinical reviews of all prior approval, post service reviews, customer service and claim requests. Determine adequacy of clinical elements of clinical information submitted. Determine essential elements of clinical information for decision-making and request same as appropriate. Make determinations based on medical policy, evidence-based guidelines, and medical necessity. Communicate directly with requesting providers to obtain additional clinical information as needed in order to make utilization management decisions. Review late and out of network prior approval / referral authorizations for appropriateness and make determination on benefit level based on medical necessity. Provide timely and accurate review for procedure/service appropriateness, reconsideration, and appeals based on Rule 9-03, DRF, and NCQA Standards. Perform monthly audits related to prior approval processes as well as weekly guidelines to confirm medical necessity and appropriateness of reviewed services. Use sound clinical judgment along with appropriate review criteria and practice guidelines to confirm medical necessity and appropriateness of reviewed services. Provide support to Provider Relations and Provider Reimbursement in regard to clinical issues relating to new procedure, coding, pricing and provider communications. Provide appropriate and timely referrals to the medical director. Identify and report any potential quality of care of services issue to the medical director. Perform timely case review information, case entry and updates to case file in the appropriate systems. Participate in medical policy committee including research and development of policies and collaboration with participating provider. Assist in review of health service delivery and utilization and cost data. Determine through clinical review members that would potentially benefit from case management. Initiate referrals to triage to assess these members for effective case management intervention. Determine and interpret member eligibility, coverage and available benefits. Contribute to member and provider satisfaction within program and organization. Assist the claims payer in accurate adjudication of care management approved services as needed.