Start Date: November 05, 2018 (long term contract)
Hours: 8 AM - 5 PM Monday - Friday
The Clinical Reviewer will independently and in a team environment to review/audit medical records against appropriate criteria in conjunction with contract requirements, critical thinking and decision making to determine medical appropriateness, while maintaining production goals and QA standards. Ensures day-to-day processes are conducted in accordance with NCQA, URAC and other regulatory standards.
- Utilizing healthcare knowledge and experience to review medical records for various types of medical services for accuracy, completeness and consistency with professional standards and compliance with contract requirements
- Documenting and reporting findings of reviews and audits in accordance with professional standards and project protocols
- Determines approval or initiates a referral to the physician consultant and processes physician consultant decisions ensuring reason for the denial is described in sufficient detail on correspondence.
- Interpreting and analyzing health care data
- Abstracts review related data/information accurately and timely on appropriate review tool by the appropriate means. Accurate and timely submission of all administrative and review related documents to appropriate parties.
- Performs ongoing reassessment of review process to offer opportunities for improvement and/or change.
- Foster positive and professional relationships and act as liaison with internal and external customers to ensure effective working relationships and team building in order to facilitate the review process.
- Responsible for attending training and scheduled meetings and for maintenance and use of current/updated information for review.
- Maintains medical records confidentiality at all times through proper use of computer passwords, maintenance of secured files, adherence to HIPAA polices.
- Utilizes proper telephone etiquette and judicious use of other verbal and written communications, following Client policies, procedures and guidelines
- Maintaining security of and confidentiality of all protected health information (PHI)
- Participating in and contributing to quality management systems
- Additional responsibilities as assigned
- Must have 2 years Prior Authorization or Utilization Review experience
- Minimum of two years of clinical experience in an acute or med-surgical environment required
- Minimum of one-year UR and/or Prior Authorization or related experience.
- Knowledge of InterQual criteria strongly preferred
- Knowledge of current NCQA/URAC standards strongly preferred
- Knowledge of the organization of medical records, medical terminology, and disease process required.
- Experience in quality improvement projects desired
- Proficient use of applicable software tools, including Microsoft Windows, Word, Excel, and Access
- Strong analytical and problem-solving skills
- Excellent communication skills including written and verbal
- Self-directed and motivated, with ability to work independently under general instructions
- Ability to work in a team environment and manage multiple deadlines and prioritize assignments
- Well organized with a high degree of accuracy and attention to detail
- Not currently sanctioned or excluded from any program operated by federal or state agencies including Medicare and Medicaid
- Current licensed practical nurse (LPN) license in good standing
- Graduation from an accredited LPN program
Astyra Corporation is a staffing and consulting company that is locally owned and operated right here in the heart of RVA. Astyra offers a unique approach to solving the business challenges of its clients. After being in business for over 20 years, we have evolved and grown - smart ideas, ingenuity and never settling for failure are our hallmark traits. We are locals with a national presence and need a like-minded; client focused professional who wants to make a difference every day.
Role: Utilization Review Nurse (LPN) (BHJOB1435_22934)
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