Specialist Clinical Review

This position is required to be onsite.

Purpose of Job

This position is responsible for utilization review activities and the provision of clinical quality support.

Job Functions

1. Provides clinical reviews for third-party payers.
2. Reviews all admissions for medical necessity.
3. Supports physician documentation initiatives.
4. Participates in ITM rounds.
5. Serves as liaison between payers, Patient Financial Services, and providers.
6. Monitors length of stay, variances, and delays in patient care and report as needed.
7. Monitors patient acuity and notifies appropriate staff of changes.
8. Reviews, supports interdisciplinary team and facilitates discharges in complex cases.
9. Performs other duties as assigned.

Minimum Education/Work Experience

• Graduate of an accredited school of nursing
• Three years of experience in medical or surgical nursing
• Recent clinical experience

Knowledge/Skills/Abilities

• Demonstrated critical thinking and decision making
• Ability to work autonomously and as a team
• Ability to respond appropriately to unpredictable situations and diverse patient populations
• Ability to maintain skills and familiarize self with new equipment and procedures as the need arises
• Ability to navigate multiple applications
• Comprehensive knowledge of Microsoft systems
• Ability to meet and maintain the necessary background checks as aligned with position function
• Ability to communicate in the English language for effective written and verbal correspondence in order to complete job functions as mentioned above

License/Certifications

• Current professional nurse licensure in Minnesota or if licensed in another state, a permit from the Minnesota Board of Nursing while the license application is in process

Preferred Qualifications

• Previous utilization review experience

Link to Employee Health Physical Demands