What are the responsibilities and job description for the Clinical Nurse Reviewer position at Phelps Health?
Phelps Health is a 2000-employee-strong hospital and healthcare system serving the heart of small-town Missouri.
No matter where you start with us, we’re committed to taking our team to the top. If you’re ready for the challenge of providing life-saving care or supporting those who do, read on to find your fit in the Phelps Health family.
General Summary
No matter where you start with us, we’re committed to taking our team to the top. If you’re ready for the challenge of providing life-saving care or supporting those who do, read on to find your fit in the Phelps Health family.
General Summary
- The Clinical Reviewer/Care Manager assists with data collection, entry and generation of reports; coordinates communication between Patient Financial Services, Third party Payers, patients, and physicians; and performs certifications, authorizations, concurrent reviews, and appeals. The clinical reviewer will be responsible for reviewing inpatient and observation patients and performing certifications/authorizations for Medicare, Medicaid, Commercial, and Medicare HMO third party payers.
- Performs pre-certification, concurrent, retrospective reviews and appeal review in an accurate and timely manner to assure reimbursement for Phelps Health.
- Communicates with Third Party Payers information related to hospitalization and continued stay.
- Communicates with Providers/Care Management/Nursing approval status from payer, issuance of Notices of Noncoverage
- Communicates findings of Utilization Reviews related to continued stay, medical necessity of admissions.
- Acts as liaison between Patient Financial Service members and Care Management team.
- Works cooperatively with physician offices, communicating necessary information to assure reimbursements, collaborates with physicians and makes appropriate recommendations regarding medical necessity for admission, continued stay, or alternative treatment facilities, agencies, and/or resources.
- Assists with communicating discharge-planning information to Third Party Payors and care providers.
- Completes appeals, back certifications, and retrospective reviews for the Denial, Prevention and Recovery Contributes to the development of a goal directed plan of care that is prioritized and based on determined medical diagnosis, patient problems, co-morbidities, and expected patient outcomes.
- Works under pressure and pays close attention to detail.
- Communicates clearly and effectively with a wide variety of individuals.
- Graduate of an approved nursing program or an equivalent combination of education and experience.
- At least two (2) years clinical experience in Utilization Management, Social Services, and/or Quality Management required. Experience working with third party payers is preferred.
- RN MO Licensure
- Considerable mental concentration required. Lifting up to 35 lbs., turning activities and nearly constant walking required. Standing, turning, carrying, pushing, pulling, stooping, crouching, twisting, and reaching.
- Frequent exposure to infectious disease and hostile persons at times. Frequent exposure to communicable disease via blood and other body fluids. Minimal physical discomfort.
