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Nurse Clinician in Memphis, TN at Integrated Resources, Inc

Date Posted: 11/24/2018

Job Snapshot

  • Employee Type:
    Full-Time
  • Location:
    Memphis, TN
  • Job Type:
  • Experience:
    Not Specified
  • Date Posted:
    11/24/2018

Job Description

Performs comprehensive pre-existing reviews, reviews of rider-related diagnoses, potential misrepresentation referrals, rider related drug appeals, provider and member appeals, denial interpretation for letters, retrospective claim review, special review requests, and UM pre-certifications and appeals, utilizing medical appropriateness criteria, nursing judgement, and contractual eligibility . Performs thorough research and provides complete documentation for rationale to support determinations as well as specific written instructions regarding additional information necessary to complete the review. Performs or participates in special studies or projects/pilots as directed by departmental management. Cross functional and accomplished in all ancillary review functions. May mentor/trains new incumbents and serve as a preceptor. Seek the advice of the Medical Director when medical judgment is required. Initiate referrals to accomplish discharge planning when such plans are evident at the time of the request e.g., telephone request for scheduled for total hip replacement. Assist non-clinical staff in performance of administrative reviews. Interact with Onsite and Case Management areas to ensure smooth transfer of member information across the continuum of care. Apply established vendor protocols for authorization processes Serves as a presentation guide for walk-through surveyors, auditors, group representatives, etc.

Quals--
Education Registered Nurse in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law required. Bachelor's degree in nursing preferred. Experience Minimum 3 years varied clinical experience required Proficient knowledge and ability to apply various accreditation requirements (URAC, NCQA, etc.) preferred. Proficient in interpreting benefits, contract language specifically symptom-driven, treatment driven, look back periods, rider information and medical policy/medical review criteria preferred. Skills/Certifications Ability to maintain professional and courteous internal communication with various departments, particularly Claims, in the exchange of information. Must be PC literate with extensive knowledge of Windows and Microsoft Office. Must be able to pass Windows navigation test. Must possess excellent verbal and written communication skills with problem-solving abilities as well as organizational and interpersonal skills. Must be able to work independently and handle multiple tasks. Customer service oriented Must be adaptive to high pace and changing environment Occasional weekend work may be required.

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