RN Clinical Reviewer-100% Remote, Home-based

Fredericksburg, VA 22402

Posted: 10/03/2021 Industry: Long Term Care Job Number: CH CR DC Fred

Job Description

Clinical Reviewer-RN

100% Remote, Home-based

Position Description

Registered Nurse to join our Care Management team who will interact with the District of Columbia and Maryland Nursing Home Facilities under a Medicaid contract to conduct periodic Nursing Home Continued Stay reviews of patients.  

Responsibilities

  • Apply clinical review criteria, guidelines, and screens to determine the medical necessity of health care services.
  • Consult with physician/practitioner consultants when reviews fail clinical review criteria, guidelines, and screens.
  • Refer cases to other professionals internally, including medical affairs consultation, as well as to customers and other appropriate external sources when indicated.
  • Provide clinical and/or review process subject matter expertise; manage complex reviews, respond to customer requests or complaints; monitor and report pertinent observations of clinical performance.
  • Provide initial clinical orientation to new employees as well as ongoing clinical mentoring and support for clinical review staff.
  • Collaborate with the clients to provide clinical expertise on complex cases and or process clarification.
  • Collaborate with Medical Affairs for complex case review and clinical topics.
  • As appropriate, provide daily oversight and monitoring of non-clinical staff during their performance of non-clinical support activities; also provide the supervisor with input regarding employees’ performance of these activities.
  • Provide clinical and/or review process subject matter expertise; respond to customer questions or concerns.

Experience

  • Computer skills, InterQual criteria experience
  • Two years + of experience and skills in work processing, familiar with database software programs ( Microsoft Office). Basis spread sheet and presentation software Applications.
  • Excellent interpersonal and problem-solving skills
  • Excellent critical thinking skills and the ability to multitask
  • Ability to organize and coordinate multiple simultaneous tasks in a team environment.
  • Ability to conduct an assessment including identifying strengths and needs, life domain functionals, risk, cultural factors, behavioral and emotional needs; assess trauma and substance sue, health and safety risks to self or others, gathering histories of mental and physical health ,substance use, past mental health services, assessing care giver resources and needs, social and work relationships; community based person centered plan review experience, community based elderly persons with disability service experiences, nursing home quality chart review with Minimal Data Set ( MDS) skill set experience;
  • Experience with Medicaid preferred.
  • Provide overall clinical knowledge and expertise for assigned contracts, client topics and problem-solving challenging cases.
  • Lead clinical training initiatives for the team in collaboration, manager/supervisor and or Medical Affairs.
  • Provide clinical mentoring and support for UM clinical review process both for new employees and for ongoing support of all clinical staff.
  • Assess and assist other reviewers to assess the medical necessity and quality of healthcare services by conducting prospective, concurrent, and retrospective utilization management reviews.
  • Strong knowledge of Medicaid, insurance utilization and quality control
  • Familiarity with InterQual and or other clinical decision medical necessity support system/tool
  • Familiarity with at least one medical management application (Jiva preferred).

Job Requirements

Qualifications

  • Experience in areas of critical care, acute care hospital experience, longer term care community based services and or other EPD Waiver service experience.
  • BA / BS in nursing preferred as well as some experience in the field of case management and or utilization review; Equivalent combination of education and/or work experience may be substituted.
  • Active, unrestricted RN Licensure in Washington, DC
  • 5 + years of clinical (direct patient care) experience, critical care and or emergency room experience preferred.
  • 1+ years of utilization review (or other medical management experience) 3 years preferred.
  • 1 + years of mental health experience preferred.
  • 1 + years of experience in clinical record review/assessment and data entry

Additional Information

Our client is a national, privately held, non-profit, financially stable company providing healthcare quality, process improvement and safety project services with federal and state organizations such as Medicare, Medicaid and Indian Health Services. They are viewed as a major player in this industry.

The is a permanent, full-time position with a market-based salary, excellent corporate benefits including full health, dental, vision (our client pays 75% of premiums for both the employer and their dependents!), 3% matching retirement, PTO and much more. In addition, they offer the PSLF-Public Student Loan Forgiveness.

Let's schedule a call to specifically discuss your career direction, our client and the position in depth. I look forward to speaking with you.

 

Regards,

Gene Doeker-President

Toll-Free 1-877-2DOEKER, 1-877-236-3537
Direct 1-318-703-3795
Mobile 1-318-207-7321
Fax 1-866-945-9598

gene.doeker@doekerresource.com

www.doekerresource.com

About Us
Doeker Resource Partners is an executive search firm providing recruiting services for placement of healthcare professionals in a variety of medical settings. Established in 2004, we saw the need for assisting healthcare providers to solve the increasing demand and more importantly the “un-met market needs” for highly qualified healthcare professionals. The quest for these professionals is more intense than ever and continues to be a major factor hindering the ability of our clients to meet the demand for their patient’s healthcare needs. Doeker’s business is to identify, qualify and successfully place the best available talent with our client companies. 
Our primary focus is directed toward Nurse Practitioners and Physician Assistants in a variety of practice specialties along with mid-to-upper level executive management positions specific to Operations, Clinical, Quality, Compliance and Business Development. 

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Gene Doeker
President

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