Inpatient Review Nurse Jobs

Engage clients in appropriate communication that manages client expectations and builds a collaborative relationship with the client

Make clinical judgments based on clinical experience when applicable

Understand and represent PRI?s mission, vision, and values to all internal and external customers

Perform medical record and claims review in accordance with all State and Federal mandated regulations

Maintain compliance with all regulation changes as they impact medical and utilization review practices

Analyze patient records and participate in interdisciplinary collaboration with PRI staff and all recognized teaming partners and/or subcontractors

Engage clients in appropriate communication that manages client expectations and builds a collaborative relationship with the client

Make clinical judgments based on clinical experience when applicable

Understand and represent PRI’s mission, vision, and values to all internal and external customers

Perform medical record and claims review in accordance with all State and Federal mandated regulations

Maintain compliance with all regulation changes as they impact medical and utilization review practices

Analyze patient records and participate in interdisciplinary collaboration with PRI staff and all recognized teaming partners and/or subcontractors

Quality of life with a remote predictable part-time schedule*

Comprehensive training and education program

You have the ability to work remotely in a comfortable environment

MD or DO degree with strong acute care clinical knowledge

Adult Internal Medicine, Emergency Medicine, Hospitalist, Nephrology, Surgeon or Infectious Disease; Board certification (preferred)

Working knowledge of hospitals’ EMR

Engage clients in appropriate communication that manages client expectations and builds a collaborative relationship with the client

Make clinical judgments based on clinical experience when applicable

Understand and represent PRI?s mission, vision, and values to all internal and external customers

Perform medical record and claims review in accordance with all State and Federal mandated regulations

Maintain compliance with all regulation changes as they impact medical and utilization review practices

Analyze patient records and participate in interdisciplinary collaboration with PRI staff and all recognized teaming partners and/or subcontractors

Experience with utilization management systems or clinical decision making tools such as MCG or InterQual.

Other duties, responsibilities, and qualifications may be required and/or assigned as necessary

Typing skills and working knowledge of computer functions and applications such as MS office (Outlook, Word, Excel).

Works collaboratively with the audit team to identify vulnerabilities and/or cases subject to potential Fraud Waste and Abuse (FWA).

Maintain a current knowledge of Medicare and Commercial regulations, policies and procedures

Maintain coding certification to ensure eligibility to perform audits on behalf of Performant

Demonstrates clinical nursing knowledge and skill based upon the needs of the patient population.

Participates in QI, CPI, and risk management activities at the unit, department, or organizational level.

Demonstrates the ability to apply knowledge of growth and development across the life span to the care of patients.

Participates in the education and/or orientation of new staff.

Demonstrates the ability to utilize various forms of technology to effectively deliver appropriate nursing care and patient education to desired population.

Demonstrates the ability to utilize telemetry as an assessment tool and manage the patient care.

Retrospective utilization management case review

Knowledge, Experience, and Key Attributes needed for Success:

2+ years of clinical nursing experience

Knowledge of Utilization Review processes

Knowledge of the medical plan appeal process (preferred)

Strong experience in clinical practice with diverse diagnoses

One to three years experience in utilization management or health services setting preferred.

Five years clinical acute care hospital experience; ICU, Emergency Medicine Department, Medical / Surgical Department.

Must have ability to work as a team player with excellent verbal and written communication skills.

Familiarity with State Federal Governmental regulations and national accrediting agency requirement preferred (CMS/NCQA or regulatory agencies).

Performs tasks requiring independent knowledge judgment in addition to instructions and procedures provided.

Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.

Three (3) years of utilization management and quality improvement experience are required.

Working knowledge and understanding of basic utilization management concepts are required.

Education, Training, And Professional Experience

Experience interpreting clinical criteria into clear determinations.

Excellent writing skills, particularly in determination notification writing.

Escalates all potential quality issues and grievances to correct Bright workflows