Clinical Review RN PRN

Cooper University Hospital

Cherry Hill, NJ 08034

Posted 1 month ago

Job 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.


Scheduled Days / Hours: as needed weekday and weekend


Bachelor’s degree in Nursing preferred


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.


Required License/Certifications/ Registration:


Current NJ-RN License required.


Requisition: 54320


Department Name: Care Management


External Company Name: Cooper University Hospital


External Company URL: cooperhealth.org


Street: 3 Executive Campus



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