RN: Clinical Utilization Review & Care Coordination

Health Care Support Staffing, Inc. (HSS), is a proven industry-leading national healthcare recruiting and staffing firm. HSS has a proven history of placing talented healthcare professionals in clinical and non-clinical positions with some of the largest and most prestigious healthcare facilities including:
Fortune 100 Health Plans, Mail Order Pharmacies, Medical Billing Centers, Hospitals, Laboratories, Surgery Centers, Private Practices, and many other healthcare facilities throughout the United States. Health Care Support Staffing maintains strong relationships with top providers in healthcare and can assure healthcare professionals they will receive fast access to great career opportunities that best fit their expertise. Connect with one of our Professional Recruiting Consultants today to see how a conversation can turn into a long-lasting and rewarding career!

Position

Purpose:

Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to emergent/urgent and continued stay reviews.

• Perform onsite review of emergent/urgent and continued stay requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations

• Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings

• Collaborate with various staff within provider networks and discharge planning team electronically, telephonically, or onsite to coordinate member care

• Educate providers on utilization and medical management processes

• Provide clinical knowledge and act as a clinical resource to non-clinical team staff

• Enter and maintain pertinent clinical information in various medical management systems

• Direct care to participating network providers

• Participate in utilization management committees and work on special projects related to utilization management as needed

Qualifications:

-RN, BSN preferred.

-2+ years of clinical nursing experience in an acute care setting

-1+ years of utilization management experience in a managed care setting. To start with this is a must!

-Knowledge of utilization management principles and healthcare managed care.

- Experience with medical decision support tools (i.e. Interqual, NCCN or Miliman) and government sponsored managed care programs
* strongly preferred but not a must

Shift

8-5

Interested in being considered?

If you are interested in applying to this position, please contact Ashley Greene at  ext 169

and click the Green I’m Interested Button to email your resume.

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