Clinical Nurse Reviewer

At VGM, we live by a common set of values that we call our power of one principles . We give our employees the freedom and resources they need, backed by our culture of collaboration and diverse thought, to continue innovating and advancing our services – if you want to be empowered to make a difference, you will love it here.

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Position Summary

Review physician orders and clinical notes to complete a detailed peer clinical review that focuses on appropriate care and patient outcomes. In collaboration with the treating provider, you will use your clinical expertise and clinical guidelines to report on the appropriateness and quality of patients’ current care as well as make recommendations on revised plan of care (e.g. level of care, frequency and duration).

Reporting Accountability: Clinical Review Manager

Working Location: Flexible with onsite, remote, or hybrid

Work Hours Classification: Full-Time, 40+ hours per week, 7am-4pm, 8am-5pm CST

Responsibilities/Duties of the Job

• Complete assigned clinical peer reviews (i.e. 30daysummary) per SOP with appropriate turnaround times and comprehensiveness of review findings and recommendations, to include review of evaluation and ongoing 30- 120 day reviews as determined based on initial peer review by nurse and per acuity level
• Review evaluations, physician orders, and progress notes to assess if the services requested or that are ongoing are adequate and appropriate for current patient status
• Review care and recommend cost savings and/or step-down care opportunities
• Perform peer calls and communicate with treating providers, referring physicians and patients to achieve non-contentious plan of treatment revisions when appropriate
• Communicate with Clinical Coordinators (CCs), or when necessary, request Patient Care Coordinators (PCCs) to obtain additional information needed to complete reviews
• Communicate with PCCs and CCs when the review is completed and document any recommended revisions to plan of treatment and needed follow-up. Maintain thorough, up-to-date documentation on each review
• Provide clinical expertise and review on adhoc basis for escalated cases and/or questions from Adjusters, Case Managers, or other internal departments ( I.e. billing, operations, account management, marketing, etc.)
• Provide clinical intake support in collaboration with PCCs and external parties (e.g. discharge planners, NCM) as needed to assist in determining initial staffing needs for new referrals
• On a rotational basis, maintain on-call nurse hours as needed. There is rotation for department on-call and back-up schedule per department procedure
• Provide oversight and monitor the Quality Improvement and Utilization Management activities of non-clinical staff, as applicable, to ensure regulatory and accreditation compliance
• Follows strict confidentiality and HIPAA privacy and security guidelines
• Maintain knowledge of various healthcare industry billing and/or coding terminologies such as ICD-10, HCPCS, CPT, modifiers, and various Medicare LCDs
• Any other duties as deemed appropriate by department management / Clinical Nurse Review Manager
  
  

Education/Experience

Position Qualifications

• Active LPN license in good standing, in a Nurse Licensure Compact (NLC) state such as Iowa. If outside the NLC, licensure is required for at least one applicable state in which business is conducted
• Preferred two (2) years of experience in an acute care setting, home care setting, and/or physician office or ambulatory setting
• Active RN licensure in good standing preferred
• Must comply with continuing education per Company, regulatory, contractual, and accreditation requirements
  
  

Skills And Competencies

• Ability to multitask and prioritize workflow is a dynamic, fast-paced work environment
• Possess strong time management and organization skills
• Work well under pressure and be punctual
• Flexible with the ability to routinely adapt to change
• Team player with excellent communication skills
• Maintain a courteous and professional demeanor in all customer interactions
• Ability to learn the Company’s care management platform and adapt to any system changes
• Knowledge of Microsoft Word, Excel, and Outlook
  
  

Physical Requirements

• Working at a physical desk, moving about the office and facility as needed for work
• Operation of office machinery and equipment
• Visual abilities to include reading, distance vision, and peripheral vision
  
  

This job description reflects the general duties of the job but is not a detailed description of all duties which may be inherent to the position. Reasonably related additional duties may be assigned to the individual Associate.

VGM Group, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, pregnancy, national origin, disability, genetic information, military or veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.