Clinical Reviewer RN
Clinical Reviewer RN
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Job Description
About Us
AtCooper University Health Care our commitment to providing extraordinary health care begins with our team. Our extraordinary professionals are continuously discovering clinical innovations and enhanced access to the most uptodate facilities equipment technologies and research protocols. We have a commitment to our employees to provide competitive rates and compensation programs. Cooper offers full and parttime employees a comprehensive benefits program including health dental vision life disability and retirement. We also provide attractive working conditions and opportunities for career growth through professional development.
Discover why Cooper University Health Care is the employer of choice in South Jersey.
Short Description
Utilizes Payer specific screening tools as a resource to assist in the determination process regarding level of service and medical necessity.
Performs utilization review in accordance with all state mandated regulations.
Consults with Physician Advisor to discuss medical necessity length of stay and appropriateness of care issues.
Identify and manage concurrent and retroactive denials through communication with attending physicians case management multidisciplinary team external physician resourcegroup and payers.
Completes documentation of review and denial processes in the EPIC Case Management Module
Responds to requests from the payer for all required information and treatment plans.
Reviews and validates physicians orders reports progress and unusual occurrences on patients to the payer.
Experience Required
35 years of recent clinical experience preferably in area of population specialty.
Experience in utilization management or review preferred.
Knowledge and understanding of disease protocols and clinical pathways for commercial and government payors. Familiarity with Interqual and Millimen guidelines and regulatory mandates preferred.
Strong communication (written and verbal) and critical thinking skills required. Professional and effective presentation skills required.
Education Requirements
Bachelors degree in nursing preferred
License/Certification Requirements
Current NJRN License required
Employment Type
Unclear
