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Clinical Care Reviewer
Ref No.: 18-01055
Location: Doral, Florida

  • Responsible for completing medical necessity reviews using Clientpolicies and procedures, reviewing inpatient and outpatient elective procedures requiring prior authorization, inpatient hospital stays, and requesting, assessing and appropriately channeling/facilitating discharge planning requests .
  • Consistently applies medical health benefit policy and medical management guidelines to authorize services.
  • Identifies and refers requests for services to the appropriate Medical Director when guidelines are not met.

  • Receives requests for authorization of services, including inpatient hospital admissions, inpatient rehabilitation services, Skilled Nursing admission), home care home infusion services, outpatient and/or inpatient elective surgery, and referrals for specialty physician consultation with non-participating physician offices. Documents date that the request was received, nature of request, utilization determination (and events leading up to the determination).
  • Verifies and documents member eligibility for services.
  • Communicates and interacts in a real time bases via "live” encounters with providers and appropriate others to facilitate and coordinate the activities of the Utilization Management process(es).
  • Utilize technology and resources (systems, telephones, etc.) to appropriately support work activities. Voice mail as an adjunct to the daily work activities versus major reliance for giving and receiving information from providers; Accessing and applying Medical Guidelines for decision making prior to Medical Director/Physician Advisor referral.
  • Applies submitted information to Clientauthorization process (utilizing Milliman, USA, Interqual medical guidelines, Process Standards, Policies and Procedures, and Standard Operating Procedures). Authorizes services in accordance with medical and health benefits guidelines.
  • Coordinates with the referral source if insufficient information is not available to complete the authorization process. Advises the referral source and requests specific information necessary to complete the process. Documents the request and follows Clientprocess for requesting additional information.
  • Refers cases to ClientMedical Director for medical necessity review when medical information provided does not support the nurse review process for giving an approval of services requested.
  • Documents case activities for Utilization determinations and discharge planning in MeDecision in a real time manner (as events occur). Completes detail line as indicated. Completes ASF per policy.
  • Provides verbal/fax denial notification to the requesting provider as per policy. Generates denial letter in a timely manner.
  • Adheres to Process Standards, Standard Operating Procedures, and Policies and Procedures, as defined by specific UM role (Prior Authorization, Concurrent Review)
  • Submits appropriate documentation/clinical information to clerical support for record keeping and documentation requirements.
  • Recognizes opportunities for referrals to Care Coordination Department, and refers accordingly.
  • Participates in Quality Reviews and Inter Rater Reliability processes and achieves performance results at or above thresholds established by management.
  • Maintains awareness and complies with Clientauthorization timeliness standards based on DPW/NCQ requirements.

Required Qualifications:
  • Current FL RN licensure
  • Registered Nurse graduated from an accredited Diploma, Associates Degree or Bachelor's Degree program
  • Minimum of 3 years of nursing experience, in related clinical setting, preferably critical care (e.g. ER, ICU)
  • Experience with Utilization Review and/or Prior Authorization
  • Familiar with Interqual Criterion
  • Knowledge of MS Office including Word, Excel, and Outlook