The Clinical Reviewer – RN’s primary responsibility is to validate that services are medically necessary and clinically appropriate. This position must reside in Kentucky or Indiana with a valid KY RN License.

Essential Function

• Responsible for the telephonic, electronic, and fax delivery, of the Utilization Management process to include: assessing, planning, implementing and, coordinating clinical recommendations regarding medical necessity and appropriate level of care

• Collects in-depth information regarding a patients clinical history, prognosis, treatment plan, response to treatment, access to care, access to personal and community resources, utilization of care, personal coping mechanisms, learning needs and financial constraints.

• Determine specific short and long-term goals, objectives, and interventions with accompanying timeframes..

• Establishes a quality check date using client specific guidelines.

• Utilizes nursing experience and judgment in addition to the client specific guidelines when determining medical necessity and quality check dates.

• Performs multiple tasks within the review process including knowledge of different systems, and the ability to interpret and apply multiple benefit configurations to the review process.

• Monitors daily work flow queues and performs necessary calls to ensure completion of reviews according to department procedure.

• Responsible for maintaining expected quality standards, -Offers suggestions for improvement in the review process.

• Maintains a courteous and professional manner in all interactions, whether with clients or co-workers.

• Perform discharge planning for the member if necessary and allowed by client contract.

• Other duties as assigned.

Requirements

• Associate’s degree in nursing. Bachelor’s degree preferred.

• Unrestricted & active Kentucky Registered Nurse. License.

• A minimum of three years clinical nursing experience preferred.

• A minimum of three years utilization management experience preferred.

• Psychiatric, Waiver, and Nursing Facility experience preferred.

• Intermediate level skills in Microsoft applications (Excel, Word, Outlook, and Windows environment).

• Excellent verbal and written communication skills.

• Organization and time management skills are essential.

• Must be able to successfully complete any required pre-employment testing.