Clinical Review Nurse

Paycor • Lake Mary, FL, United States • $200k - $250k / year • 1w ago

TurningPoint Healthcare Solutions is a rapidly growing and innovative healthcare company that supports several large national health plans to improve the quality and affordability of healthcare patients receive. We are looking for motivated individuals who want to be part of our mission and join our team!

As a Utilization Review Nurse, you will utilize your critical thinking skills, clinical expertise and judgement along with established medical criteria to perform first level clinical review for select procedures that require medical necessity authorization. We are seeking individuals who enjoy a challenge, have an ability to work independently and are capable of meeting deadlines. Previous utilization management experience is preferred. In addition to prior experience, the ideal candidate will have an extreme attention to detail, an ability to flourish in a fast-paced environment and advanced grammar, punctuation, and computer skills.This is a fully remote position with multiple shifts available!

Responsibilities

Perform initial clinical reviews and provide documented recommendations based on the use of appropriate clinical guidelines
Review the initial evaluation and clinical documentation against clinical standards, applicable state regulations and relevant treatment guidelines
Assist clinical staff in quality improvement projects to provide instructive feedback to clients and providers within scope of practice
Resolve patient care issues by working one-on-one with community providers and staff to resolve issues in the determination process
Provide information by responding to queries of physicians and their practice staff, sorting and distributing messages and documents, and preparing information for determinations
Improve quality results by studying, evaluating procedures and processes and recommending changes, if needed
Serves and protects the company by adhering to accreditation standards, professional standards, company policies and procedures, federal, state, and local requirements, and professional and licensing standards

Qualifications:

Licensed Nurse Practitioner (LPN) or Registered Nurse (RN) required
Comprehensive knowledge of general nursing theory and practices
Excellent customer service skills and phone etiquette
Proficient computer skills, including typing and an ability to maneuver through various programs
Previous Utilization Management experience preferred but not required
Knowledge of musculoskeletal surgical procedures, cardiac procedures, pain management and/ or wound care is a plus
Ability to multi-task and manage tasks to completion on a timely basis and in an organized fashion
Ability to work collaboratively as part of a team

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