Clinical Reviewer
*This is a part-time role, 3 days per week, 8-hour shift.
Job Summary:
The Utilization Review Nurse is responsible for reviewing and interpreting medical records against established criteria, contract requirements, and regulatory standards to determine medical necessity and appropriateness of care. This role applies critical thinking and clinical judgment to ensure accurate decisions while meeting productivity goals and quality assurance benchmarks. Utilization Review/Management responsibilities span multiple service categories, including Durable Medical Equipment (DME), acute care, inpatient admissions, third-party outpatient services, imaging, genetic testing, and other medical services.
Responsibilities:
- Review and assess patient medical records to determine medical necessity and appropriateness of requested services in accordance with clinical criteria, contract guidelines, and regulatory standards.
- Ensure accuracy and timeliness of all assigned review cases within established contract and departmental requirements.
- Evaluate daily workload queues and adjust work schedules as needed to meet departmental productivity demands.
- Collaborate with supervisory staff to support quality monitoring activities and continuous improvement initiatives.
- Maintain current knowledge of utilization review processes, clinical practices, and applicable medical necessity criteria, serving as a resource for nurse reviewers regarding review-related concerns.
- Act as a liaison for provider customer service issues, supporting effective problem resolution and communication.
- Perform utilization review across service categories, including DME, acute care, inpatient, outpatient, imaging, genetic testing, and other related medical services, as workload indicates.
- Foster positive and professional relationships with internal and external stakeholders to support teamwork and facilitate the review process.
- Attend required training sessions and scheduled meetings to ensure continued compliance with updated review standards and procedures.
- Cross-train to provide workforce flexibility and meet client/customer needs across multiple service areas.
- Maintain confidentiality of medical records through adherence to HIPAA privacy and security policies and proper handling of sensitive information.
- Read, understand, and comply with all corporate policies and procedures, including those related to HIPAA regulations.
Required Qualifications/Experience:
- Active, unrestricted Registered Nurse (RN) license issued by the State of Illinois
- A minimum of a diploma, certificate, or degree in Nursing.
- 3+ years of clinical experience in an acute, behavioral health, and/or med-surgical environment.
- 2+ years of Utilization Review/Management (UR/UM) and/or Prior Authorization experience.
- Experience reviewing medical necessity for services including DME, acute care, inpatient, TPO, imaging, genetic testing, and other related categories.
- 1+ years of knowledge of InterQual criteria, Milliman Care Guidelines (MCG), and/or other state/nationally recognized criteria.
- Proficient in navigating multiple systems with the ability to switch between systems seamlessly and effectively.
- Strong clinical assessment and critical thinking skills.
- Excellent written and verbal communication skills.
- Flexibility and strong organizational skills.
Preferred Qualifications/Experience:
- An Associate, Diploma, or Bachelor’s degree from an accredited college or university in Nursing or a related field.
- Knowledge of current National Committee for Quality Assurance (NCQA) standards.
- Knowledge of Utilization Review Accreditation Commission (URAC) standards.
- Ability to work in a team environment.
- Proficient in Microsoft Office.
- Efficient time management, including the ability to prioritize tasks and meet deadlines.
- Exhibit the ability to maintain confidentiality standards and ensure HIPAA compliance when assessing relevant issues.
Proper email communication will only be done to and from @astyra.com email addresses. Please ensure you are communicating with approved Astyra recruiters by checking this point when receiving offers and messages from us. Please ensure you are communicating within these guidelines and proper channels for the quickest possible interview consideration!
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