Clinical Reviewer RN
Cooper University Health Care
Date: 5 days ago
City: Camden, NJ
Contract type: Full time
- Utilizes Payer specific screening tools as a resource to assist in the determination process regarding level of service and medical necessity.
- Performs utilization review in accordance with all state mandated regulations.
- Consults with Physician Advisor to discuss medical necessity, length of stay, and appropriateness of care issues.
- Identify and manage concurrent and retroactive denials through communication with attending physicians, case management, multidisciplinary team, external physician resource group and payers.
- Completes documentation of review and denial processes in the EPIC Case Management Module
- Responds to requests from the payer for all required information and treatment plans.
- Reviews and validates physician’s orders, reports progress and unusual occurrences on patients to the payer.
- Effective problem-solving skills, including the ability to analyze complex situations, draw conclusions and implement actions appropriately and efficiently.
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