Review Nurse Job Description
Review nurse
provides support and assistance to attorneys in prosecution of Medicaid fraud and alleged patient abuse, patient neglect.
Review Nurse Duties & Responsibilities
To write an effective review nurse job description, begin by listing detailed duties, responsibilities and expectations. We have included review nurse job description templates that you can modify and use.
Sample responsibilities for this position include:
Manages all direct admits, clarifying level of care orders and performing Milliman/InterQual screening as appropriate
Appropriately document all reviews, authorizations and adverse determinations in the Member file
Demonstrate on-call triage knowledge
Serve as a medical subject matter expert
Serve as a consultant to case managers
Comparing UAS and Case Trakker to ensure correlation
Reviewing UAS based on the organization's correlating training
Weekly report to management on UAS reviews
Ensuring that proper documentation is completed in Case Trakker
Providing Field Assessors with feedback on their documentation guide them towards documentation improvement
Review Nurse Qualifications
Qualifications for a job description may include education, certification, and experience.
Licensing or Certifications for Review Nurse
List any licenses or certifications required by the position: ABQAURP, HIAA, BLS, CCM, AHA, CPR, CMCN, DHCS, UR, PRI
Education for Review Nurse
Typically a job would require a certain level of education.
Employers hiring for the review nurse job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and Associate Degree in Nursing, Education, Graduate, School of Nursing, Healthcare, Computer, Health, Associates, Management, Medical
Skills for Review Nurse
Desired skills for review nurse include:
Medicare
HIPPA and NCQA standards
Health Services policies and procedures
Medical coding
InterQual
Fraud
Internet and e-mail
Medicaid/Medicare claims and reimbursement requirements to make accurate claim determination
Medical terminology
Waste and abuse definitions to identify and participate in fraud referral when indicated
Desired experience for review nurse includes:
Identifying and assisting with Nurses continuing education and training of the organization's policies and procedures for UAS and Case Trakker assessment
Assess patient's clinical needs against established guidelines and/or standards
Coordinate with patient, family, physician, hospital and other external customers with respect to the appropriateness of care
Coordinate the delivery of high quality, cost-effective care supported by clinical practice guidelines established
Monitor patient's medical care activities, regardless of the site of service, outcomes for appropriateness and effectiveness
Collect relevant medical information
Review Nurse Examples
1
Review Nurse Job Description
Job Description Example
Our growing company is looking to fill the role of review nurse. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for review nurse
- Comprehensive medical documentation review
- Educate clinical staff regarding accurate and complete description of patient status based on CMS guidelines
- Performs comprehensive medical documentation review of eHRA
- Conduct quality assurance audits of various organization staff practices to ensure compliance with policies and procedures
- Collects, reviews and analyzes data to ensure effective utilization of resources
- Evaluates program effectiveness and delivery of services
- Develops reports and reports findings/ recommendations to the Quality Assurance Manager, the organization's management staff, other related staff and Quality Assurance committees
- Demonstrates basic problem solving skills to ensure early intervention and identification of those injuries which will benefit from medical case management or to identify questionable claims during the utilization review process
- Coordinates pre-determinations for specific procedures maintaining confidentiality of all patient related information
- Learn and use company tools and processes to perform and properly track all utilization reviews
Qualifications for review nurse
- Must be able to maintain the highest level of confidentiality and professionalism at all times
- Utah State RN license or Interstate Compact License accepted
- Works with Discharge Planner and RN to ensure discharge planning process is active and meets the needs of the patient
- Participates with RN nursing staff in Treatment Planning to ensure plan meets patient's clinical, psychological and discharge needs in collaboration with the attending physician and interdisciplinary team
- Evaluates the health status of assigned patients by collecting and analyzing patient and family data, and expedites and coordinates the delivery of services to facilitate patient’s progression through the healthcare system
- Three years of recent nursing experience in acute care setting
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Review Nurse Job Description
Job Description Example
Our company is hiring for a review nurse. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for review nurse
- Perform utilization
- Reviews concurrent and or retrospective acute care medical necessity denials for concurrence and submit timely appeals or complete status changes as necessary
- Documents all denials and appeal process in the denial software
- Works with the Compliance Nurse Manager Auditor to identify needed educational opportunities for Case Management staff and Physicians
- Work with case managers to ensure authorization and certifications of hospital days have been approved by payer
- Work with case managers to ensure clinical reviews are submitted to payer timely for approval for medical necessity continued stay days and avoid a potential non- clinical submission denial
- Utilize clinical knowledge and experience with disease management and medical services rates, including payer contracts, during the negotiation for a reverse decision of a potential front –end denial
- Reports denial activity and reports at monthly revenue management meetings
- Provides support/guidance to RN Case Managers regarding concurrent denials and appropriate patient status determinations
- Supervises, evaluate and or coordinate care management processes/denial prevention, and or denial and appeals management, maintaining regulatory compliance
Qualifications for review nurse
- Knowledge of healthcare and managed care preferred
- Washington RN license
- Maintain good intradepartmental and community relationships
- Behave in ethical and honest manner to foster trust
- Current TN RN licensure required
- Working knowledge of reimbursement issues
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Review Nurse Job Description
Job Description Example
Our company is hiring for a review nurse. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for review nurse
- Identifies and/or clarifies inpatient vs
- Reviews member in-patient medical records and conducts concurrent review to assess the appropriateness of the hospital setting
- Evaluates for the appropriate level or location of care and anticipated length of stay
- Communicates with the admitting and primary care physicians on an on-going basis
- Participates in patient conferences, family conferences and regular staffing for in-patient admissions
- Documentation of information from the patient’s hospital record will be done as necessary along with documentation on discharge planning and interactions with hospital staff, physicians, and vendors
- Coordinates home health care and durable medical equipment services and notifies the agencies of their needed services
- Functions as liaison and problem solver for all concurrent review related issues
- Participates in gathering and reporting data to include quality and utilization indicator information and other applicable information
- Assists in developing standards and outcomes for all discharge and case management functions
Qualifications for review nurse
- Registered Nurse (RN) or Licensed Practical Nurse (LPN) in the state of Connecticut
- Must possess excellent oral communication/telephone skills
- Ability to work well in a high stressed, fast paced, constantly evolving environment
- Familiarity with coding principles to include ICD-9, ICD-10, CPT, HCPCS, DRG and RBRVS
- Associate’s degree in Nursing /Bachelor’s degree in Nursing is preferred
- Minimum 5 years in clinical setting (hospital, nursing home, home health)
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Review Nurse Job Description
Job Description Example
Our company is growing rapidly and is looking to fill the role of review nurse. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for review nurse
- Follows job work aide in sequence of performing job, including checking eligibility on health plan websites
- Preps case thoroughly, concisely and clearly for physician review
- Screens selected medical records in accordance with contractual agreements and departmental policies for appropriateness of admission
- Reviews and/or coordinates requests for authorization of specialty services with external consultants, and Physician Advisors
- Perform clinical reviews using HPHC criteria and guidelines to determine when services are medically necessary and appropriate
- Analyze and evaluate medical records and other health data to render medical necessity determinations using specific clinical criteria while adhering to regulatory turn-around times and provide review outcomes to members and providers in accordance with notification standards
- Review outpatient pre-authorization requests and/or retrospective requests through claims review and incoming requests through fax, electronic authorization platform, or telephone to ensure medical necessity for services requiring pre-authorization
- Proactively and collaboratively interface with physicians, internal staff, members and members' families to assist in expediting appropriate discharge, obtain authorizations, and direct toward medically necessary care
- Conducts concurrent reviews for inpatient stays (hospital, Skilled Nursing Facility, Rehab, Long Term Care Hospitals, ) and for Home Health agency services
- Coordinates and acts as a resource to the facility Care Management staff in managing transition of care from the facility to alternative level of care
Qualifications for review nurse
- Three (3) years of Utilization Management (Precertification, Case Management, Disease Management, Retrospective Review) preferred
- RN with current unrestricted License in State of Arizona
- Minimum of one (1) year experience in Managed Care and/or three (3) years experience in UR/UM
- Case management or concurrent review experience preferred
- Arizona State issued driver’s license
- Must have own reliable transportation with appropriate insurance
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Review Nurse Job Description
Job Description Example
Our growing company is hiring for a review nurse. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for review nurse
- Demonstrate a working knowledge of care management referral criteria, skills related to service, cost evaluation and member satisfaction to effectively identify opportunities and coordinate referrals for care management intervention
- Perform all required documentation and entry into utilization management operating system for authorization and determination
- Contribute to the effectiveness and efficiency of the department
- Participates on a variety of forums to improve department process, opportunities for appropriate cost-containment, and improved member satisfaction
- Demonstrates business management skills related to service cost evaluation, and complies with company policy/procedures/standards
- Consistently adhere to department productivity and performance expectations
- Consistently demonstrates an attitude of customer service excellence to both internal and external customers
- Accurately screens medical records for quality / risk indicators
- Abstracts and reports required quality data accurately and timely to the appropriate entity Core Measures, MBQIP, Meaningful Use
- Maintains up to date knowledge of quality measure requirements for various agencies CMS, The Joint Commission, MBQIP, CHI
Qualifications for review nurse
- Registered Nurse with current RN license in good standing required
- Licensed RN in the state of NJ, BSN preferred
- In-depth knowledge of Home Health regulations
- Three or more years of experience in patient care acute facility, preferably at a tertiary care medical center
- Requires dexterity to perform work on a PC
- 3-5 years of clinical experience and/or case management, utilization review, and/or discharge planning experience in an acute care setting, insurance company or other healthcare related field (home health, hospice, SNF)