Clinical Program Nurse (Finance)
Position is responsible for the clinical oversight of the Physician Review Services coordination team, assuring compliance with jurisdictional and stand-alone-client requirements. The nurse will focus on contributing to the appropriateness and effectiveness of clinical products and programs developed by and/or supported by the Medical Department. In addition, the nurse will be a liaison to the other medical management departments.
- ASN degree or education equivalent to a college degree or industry work related experience. BSN/MSN is preferred.
- 5 + years of clinical nursing
- Managed care experience
- Supervisory experience
- Basic office equipment (copy machine, scanning, fax)
- Microsoft Office, Teams
- Articulate oral communication
- Professional written communication
- Organizational /management skills
- Clinical guidelines and criteria
- Evidence-based-medicine
- Individuals who conduct initial clinical review must possess a current, professional license or certification in good standing and without restrictions with the home state:
- To practice as a health professional in a state or territory of the U.S.; and
- With a scope of practice that is relevant to the clinical area(s) addressed in the initial clinical review.
- Must complete continuing education requirements as outlined by Crawford Educational Services.
- Assists with managing the Physician Review Services (PRS) coordination team operations. Acts as a resource for interpreting clinical scenarios and assists in the determination of assignment to the appropriate clinical specialty for peer reviews.
- Assists with onboarding of physicians to physician peer review panel to include collaborative training on the PRS system and access to evidenced based guidelines.
- Monitors and documents case activities in a timely manner.
- Reviews member's medical record and medical aspects of claim while applying critical thinking to various clinical scenarios.
- Interprets & applies appropriate clinical criteria when making clinical decisions or refers to appropriate physician peer reviewer to determine appropriate treatment and level of care.
- Addresses customer inquiries/concerns regarding clinical issues within PRS and stand-alone business reviews/reports.
- Participates in the QI Committee and QI project as assigned/necessary.
- May perform other duties as assigned.
