What are the responsibilities and job description for the CLINICAL REVIEWER RN position at Cooper University Health Care?
About Us
At Cooper University Health Care, our commitment to providing extraordinary health care begins with our team. Our extraordinary professionals are continuously discovering clinical innovations and enhanced access to the most up-to-date facilities, equipment, technologies and research protocols. We have a commitment to our employees by providing competitive rates and compensation, a comprehensive employee benefits programs, attractive working conditions, and the chance to build and explore a career opportunity by offering professional development.
Discover why Cooper University Health Care is the employer of choice in South Jersey.
Short Description
At Cooper University Health Care, our commitment to providing extraordinary health care begins with our team. Our extraordinary professionals are continuously discovering clinical innovations and enhanced access to the most up-to-date facilities, equipment, technologies and research protocols. We have a commitment to our employees by providing competitive rates and compensation, a comprehensive employee benefits programs, attractive working conditions, and the chance to build and explore a career opportunity by offering professional development.
Discover why Cooper University Health Care is the employer of choice in South Jersey.
Short Description
- Utilizes Payer specific screening tools as a resource to assist in the determination process regarding level of service and medical necessity.
- Performs utilization review in accordance with all state mandated regulations.
- Consults with Physician Advisor to discuss medical necessity, length of stay, and appropriateness of care issues.
- Identify and manage concurrent and retroactive denials through communication with attending physicians, case management, multidisciplinary team, external physician resource group and payers.
- Completes documentation of review and denial processes in the EPIC Case Management Module
- Responds to requests from the payer for all required information and treatment plans.
- Reviews and validates physician’s orders, reports progress and unusual occurrences on patients to the payer.
- 3-5 years of recent clinical experience, preferably in area of population specialty.
- Experience in utilization management or review preferred.
- Knowledge and understanding of disease protocols and clinical pathways for commercial and government payors. Familiarity with Interqual and Millimen guidelines and regulatory mandates preferred.
- Strong communication (written and verbal) and critical thinking skills required. Professional and effective presentation skills required.
- Current NJ-RN License required
- Effective problem-solving skills, including the ability to analyze complex situations, draw conclusions and implement actions appropriately and efficiently.
