Flexispot E7 Vs E7 Pro Review Jobs in Usa

Summary:

The Utilization Review Nurse is responsible for determining the clinical appropriateness of care provided to patients and ensuring proper hospital resource utilization of services. This nurse is responsible for performing a variety of pre-admission, concurrent, and retrospective UM related reviews and functions. They must competently and accurately utilize approved screening criteria (InterQual/MCG/Centers for Medicare and Medicaid Services “CMS” Inpatient List). They effectively and efficiently manage a diverse workload in a fast-paced, rapidly changing regulatory environment and are responsible for maintaining current and accurate knowledge regarding commercial and government payors and guidelines related to UM. This nurse effectively communicates with internal and external clinical professionals, efficiently organizes the financial insurance care of the patients, and relays clinical data to insurance providers and vendors to obtain approved certification for services. The Utilization Review Nurse collaborates as necessary with other members of the health care team to ensure the above according to the mission of CHRISTUS.

Responsibilities:

• Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
• The prior authorization role completes an assessment of a proposed service to determine if the beneficiary has eligible coverage for the service and if it is medically necessary.
• Promote quality, cost-effective outcomes through prior authorization and concurrent review of requested services for medical necessity based upon evidence-based clinical guidelines.
• Identify and present cases of possible quality of care deviations, questionable admissions, and prolonged lengths of stay to the Medical Director for further determination.
• Appropriately refer beneficiaries who have complex or chronic conditions, a need for transition of care, disease management support, or other identifiable needs for coordination of the beneficiary’s member’s health care for behavioral health care management.
• Follow CHRISTUS Health Guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent, or detect unauthorized disclosure of Protected Health Information (PHI).
• Protect the confidentiality of data and intellectual property; assures compliance with national health information guidelines.
• Analyze clinical information submitted by medical providers to evaluate the medical necessity, appropriateness, and efficiency of the use of medical services, procedures, and facilities.
• Perform provider outreach to address post-hospital discharge services, redirection to in-network providers for appropriate steerage, durable equipment usage, and utilization of other medical services and/or procedures and other necessary telephonic follow-up.
• Utilize the nursing process and critical thinking skills to provide oversight of services and evaluation of service options.
• Ability to work in a variety of settings with culturally diverse communities with the ability to be culturally sensitive and appropriate. 
• Must have excellent communication skills (written and verbal), clinical judgment, initiative, critical thinking, and problem-solving abilities.
• Must be able to take after hour calls to meet business requirements as needed.

Job Requirements:

Education/Skills

• Graduate of an accredited school of vocational nursing or equivalent required
• Associate’s (ADN) or Bachelor’s (BSN) in Nursing preferred

Experience

• 3 – 5 years of nursing experience preferred
• Experience in Microsoft software (e.g., Outlook, Teams, Word, and Excel) required
• General computer knowledge and capability to use computers required

Licenses, Registrations, or Certifications

• LVN license in the state of employment or compact required
• RN license in state of employment or compact preferred

Work Schedule:

5 Days - 8 Hours

Work Type:

Full Time

Conducts comprehensive clinical reviews of adverse determinations related to medical necessity.

Initiates outreach to providers to obtain clarification or additional documentation in alignment with established clinical criteria and organizational policies, to support Medical Director decision making.

Provides support for claim appeals in relation to medical necessity.

Ensures the timely and accurate resolution of appeal cases and supports organizational adherence to all state, federal, and accreditation standards.

Facilitates member second level appeal process.

Graduate from an accredited school of professional nursing is required.

BSN preferred.

Minimum 2 years acute care experience or managed care experience is required.

Basic knowledge of Medicaid, Medicare preferred.

Knowledge of InterQual screening criteria, ICD-10, CPT coding preferred.

Current Registered Nurse (RN) license to practice professional nursing issued by the Board of Nurse Examiners for the State of Texas is required.

Active Certification in Case Management (CCM) is preferred.

Conducts comprehensive clinical reviews of adverse determinations related to medical necessity.

Initiates outreach to providers to obtain clarification or additional documentation in alignment with established clinical criteria and organizational policies, to support Medical Director decision making.

Provides support for claim appeals in relation to medical necessity.

Ensures the timely and accurate resolution of appeal cases and supports organizational adherence to all state, federal, and accreditation standards.

Facilitates member second level appeal process.

Graduate from an accredited school of professional nursing is required.

BSN preferred.

Minimum 2 years acute care experience or managed care experience is required.

Basic knowledge of Medicaid, Medicare preferred.

Knowledge of InterQual screening criteria, ICD-10, CPT coding preferred.

Current Registered Nurse (RN) license to practice professional nursing issued by the Board of Nurse Examiners for the State of Texas is required.

Active Certification in Case Management (CCM) is preferred.

The Utilization Review Physician collaborates with the healthcare team in the management and resolution of activities that assure the integrity of clinical records for the patient population and Hackensack University Medical Center.

These include but are not limited to utilization review, hospital reimbursement, clinical compliance, case management, and transitions of care, as outlined in the responsibilities below.

Education, Knowledge, Skills and Abilities Required: 1.

This position coordinates utilization review service for defined patient populations across the acute care continuum. This includes discharge planning, utilization management, care coordination collaboration, and support for resource utilization. This position works collaboratively with an interdisciplinary team to improve patient care through the effective utilization of the facility's resources.

1. Current licensure as a Registered Nurse (RN) in the state of California is required.

2. Current American Heart Association (AHA) Healthcare Provider CPR card is preferred.

3. Degree from an accredited baccalaureate nursing program (BSN) is preferred.

4. Certified Case Manager (CCM) national certification is preferred.

5. Interquel training must be obtained within six (6) months of hire into position.

6. Previous experience in at least two (2) areas of clinical specialty in an acute care setting is required.

7. Excellent communication skills, critical thinking, creative problem-solving skills, and competent organizational and planning skills are required.

8. The incumbent must be self-directed and able to tolerate frequent interruptions with a demanding workload.

9. Knowledge regarding hospital protocol and procedures, clinical standards and outcomes, funding options, familiarity with community resources and outside professional agencies, familiarity with federal and state regulations governing hospital and home care, as well as understanding of the financial structure of health plan and delivery system is preferred.

Pay Range:

$49.47 - 71.74

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.

Position Title: Medical Reviewer

Work Location: Remote

Assignment Duration: 12 Months

Job Description:

We are seeking a contract Medical Reviewer to support our international Botox Therapeutic Neurotoxin team. The ideal candidate will be responsible for the medical review of clinical and scientific data related to the use of Botox for various therapeutic indications.

Key responsibilities include ensuring the accuracy and compliance of content with regulatory and company standards, providing expert medical input on clinical documents and safety information, and collaborating with cross-functional teams globally.

Qualifications:

The candidate should have a medical degree (MD or equivalent), clinical experience in neurology, physical medicine, or related fields, and a solid understanding of regulatory requirements for therapeutic neurotoxins. Experience with Botox or neurotoxin therapies is strongly preferred. Excellent communication and detail-orientation are essential.

Must have experience as a Reviewer OUS, understanding regulatory complexities of international markets.