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Intelligent Medical Solutions - IMS · 1 day ago

Initial Clinical Reviewer

Florida, United States

Full-time

Onsite

Mid, Senior Level

$62K/yr - $82K/yr

5+ years exp

Intelligent Medical Solutions - IMS is seeking an Initial Clinical Reviewer to apply technical knowledge in utilization management. The role involves assessing the medical necessity of provider requests for services and performing various utilization management activities according to state guidelines.

Information TechnologyInsuranceSoftware

Responsibilities

Reports to Vice President of Managed Care

Responsible for performing prospective, concurrent, and retrospective utilization management activities as per specified state UR guidelines by utilizing clinical expertise, judgment, and established medical criteria

Determine whether to authorize medical treatment or escalate to an appropriate physician specialist and provide rationale for doing so

Manages and follows relevant time frame standards for conducting and communicating utilization review determinations

Maintain knowledge of and is compliant with state specific UR guidelines

Prepare and maintain accurate quality data on all utilization management activities

Ensures the content, format, and professional appearance of the reports are of the highest quality and in compliance with company standards

Collaborate with the IMS UR team and participate in regular department and committee meetings as appropriate

May provide guidance and coaching to other initial clinical reviewers and participate in the orientation of newly hired initial clinical reviewers

Answers Utilization Management directed telephone calls; managing them in a professional and competent manner

Qualification

RNLPN/LVN licenseUtilization Review experienceClinical experienceMS WordExcelCommunication SkillsInterpersonal SkillsOrganization Skills

Required

Graduate of an accredited school of nursing

Current RN or LPN/LVN license to practice as a health professional in a state or territory of the United States and the license is recognized in the relevant jurisdiction

License is unrestricted, and if restricted that is allowed by relevant jurisdiction it is of the type that does not affect the ability to fulfill the roles and responsibilities of the position

Minimum of three years of clinical experience

Possesses and can demonstrate the professional and technical skills of an RN and/or LPN/LVN

Excellent Written and Oral Communication Skills

Excellent Interpersonal Skills

Strong Organization Skills

High comfort level with computers and computer programs (MS Word, MS Excel, Email)

Ability to work independently with minimal supervision

Ability to meet deadlines in a high pressure, time sensitive environment