Summary of Position Direct supervision of the Clinical Nurse Reviewer staff, oversee the clinical team and operational functions related to the review of clinical records and service appeals for purposes of providing clinical summaries on clinical appeals. Responsibilities: * Under the direction of the director, is responsible for the execution of efficient departmental processes designed to oversee the medical review process for clinical appeals and par provider retrospective utilization reviews, ensuring all cases sent for medical review meet regulatory and departmental timeframes. Evaluates the medical review process and recommends process improvements.
* Responsible for the supervision of the clinical staff, ensuring the timely and appropriate execution of day-to-day inventory and quality management.
* Performs ongoing analysis to make recommendations to the department director regarding volume, case type, etc. Make recommendations to the department director regarding corrective action and/or counseling as needed, in addition to developing processes and procedures that improve the quality and processing of clinical reviews.
* Create visibility and support for payment review programs for internal and external customers. Collaborate with interdepartmental leaders to resolve issues and improve processes and workflows.
* Organizes after-hour and weekend coverage, as required.
* Coach and mentor to staff.
* Ensures compliance with State, Federal and NCQA requirements related to utilization management activities.
* Under the direction of the Director; trains, evaluates and develops assigned staff.
* Develops, monitors, and communicates performance expectations and plans for all direct reports and conducts performance reviews within specified timeframe. Provides feedback on a regular basis. Assists with resolution of employee performance issues.
* Maintains an environment of quality improvement through continuous evaluation of processes and policies. Identifies and recommends new technologies and process efficiencies.
* Interacts with various departments throughout the organization and contributes to the resolution of interdepartmental issues. Leads and develops team to quickly assess and diagnose root causes to problem areas.
* Actively participates on assigned committees and projects.
* Performs duties of a clinical reviewer as needed
* Performs other duties as assigned.
Qualifications: * Bachelor's Degree in Nursing preferred, health care, or business, or an equivalent combination of education and experience
* LPN/RN
* Active unrestricted license or certification required.
* At least 4-6 years of clinical experience required
* At least 2 years of managed care experience preferred
* Supervisory experience preferred
* State of the art knowledge of care management tactics
* Strong oral and written communication and interpersonal skills
* Strong organizational skills
* Strong knowledge of Microsoft Office products including Word, Excel, and Access Additional Information
- Requisition ID: 1000002282
- Hiring Range: $63,000-$110,000
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EmblemHealth
Jan 23, 2025