Clinical Review Nurse - 216041

Medix Healthcare is currently hiring a Clinical Review Nurse for one of the nation's most experienced healthcare quality improvement organizations. This position will be fully onsite at the office in New Hyde Park, NY. We are looking for Registered Nurses that have strong clinical or administrative experience looking to get out of bedside. The RN must have their BSN.

Schedule: Monday - Friday 8:30-5p

GENERAL RESPONSIBILITIES:

This individual will complete the full spectrum of activities related to State and Federal Independent Dispute Resolution (IDR) case determinations. They will conduct clinical

level review, Prior Authorization and disputed benefits review, supporting Medical Review Analysts, and Physician Consultants to ensure an appropriate and accurate process.

DUTIES:

• Conduct reviews up to and including the appeal level. This includes chart screen, compiling regulatory guidance, researching insurer requirements,complete electronic worksheets and prepare final determinations.
• Act as a resource for the administrative and clinical staff in training, problem solving, and clarifying determinations. Will provide technical assistance and conduct/participate in staff huddles.
• Participate in collaborative training.
• Other activities may be deemed necessary.

QUALIFICATIONS:

1. Licensed as a Registered Professional Nurse in New York State.
2. Bachelors of Science in Nursing
3. Knowledge and experience with electronic medical records.
4. Ability to oversee, problem solve and work collaboratively with peers, medical, analytical, and administrative support staff.
5. Excellent written and verbal skills.
6. Ability to work independently with little supervision.
7. Ability and desire to be flexible, innovative, and creative.
8. Ability to meet deadlines in time sensitive environment.