Job Summary
The position entails overseeing clinical review operations, where the main focus is on addressing intricate guideline inquiries, performing case evaluations, handling case inventory, ensuring timely processing, and managing workflows for physician reviewers. The role is pivotal in maintaining communication and supporting the nursing team while upholding set productivity and quality benchmarks.
Responsibilities
- Resolve complex guideline questions within clinical review operations.
- Conduct comprehensive case reviews to ensure compliance and quality.
- Manage the inventory of cases and adhere to turnaround time expectations.
- Coordinate workflows for physician reviewers effectively.
- Audit and mentor nursing staff to improve performance and quality.
- Support training initiatives and strengthen team communication.
- Provide secondary coverage for Nursing Management as needed.
Qualifications
- Graduation from an accredited nursing program with an active, unrestricted RN or LPN/LVN license in the U.S.
- A minimum of three years of experience in prospective utilization management.
- Proven track record of achieving productivity and quality standards.
- Extensive knowledge of evidence-based criteria and regulatory/accreditation standards.
- Proficiency in Excel and operational reporting.
- Excellent communication skills, with experience in team auditing, training, or leadership roles.
