PreCert Nurse / Utilization Review Nurse

Requirements:
Essential Job Functions:

• Comprehension of medical/surgical modalities and imaging techniques
• Analysis of clinical documentation in relation to medico-legal review
• Collect data and analyze information to make decisions regarding certification or denial of treatment. Work must be completely documented.
• Audit and analyze patient records to ensure quality patient care and appropriateness of services
• Utilize pre-approved criteria and guidelines to validate medical necessity/appropriateness of treatment (e.g. ODG, MTUS, Milliman Care Guidelines, Interqual)
• Interpret and apply appropriate guidelines to medico-legal reviews
• Use logic and reasoning to determine and utilize appropriate evidence-based guidelines
• Perform a low to moderate amount of research on a case by case basis
• Create a high-quality, professional report free of grammar or spelling errors
• Dictate all report information
• Communicate with physicians to correct errors or omissions and to investigate questionable claims
• Analyze information gathered by investigation and report findings and recommendations
• Responsible for amending reports when necessary with any additional clinical information provided
• Participates in an interdisciplinary health care team to achieve positive outcomes
• Reach and maintain a 25-30 average daily case load once released from training
• Maintain a monthly Quality Assurance score of 99% or higher
• Requires regular and consistent attendance
• Other duties as assigned

Knowledge and Abilities Requirements:

• Knowledge of Basic Anatomy
• Comprehension of medical/surgical modalities and imaging techniques
• Ability to analyze clinical documentation in relation to utilization reviews
• Ability to Interpret and apply appropriate guidelines to utilization reviews
• Ability to use logic and reasoning to determine and utilize appropriate evidence-based guidelines
• Ability to read, analyze, and interpret documents, reports, technical procedures, governmental regulation, and correspondence.
• Ability to write routine reports and correspondence; and ability to present information in one-on-one, small group, and large group situations to management and staff.
• Ability to apply proper grammar, spelling, punctuation, and format to typed material. Must have excellent oral and written communications skills.
• Ability to use Microsoft products: Word, Excel, PowerPoint, Outlook
• Basic computer skills to include saving, copying, pasting, scrolling, etc.
• Written and verbal communication skills with a demonstrated ability to deliver excellent customer service
• Communicate professionally with physicians and clients
• Ability to multi-task and quickly adapt in a fast-paced environment
• Maintain a positive attitude and outstanding customer service while working closely internally with Nexus team-members, panel physicians and clients.
• Strong organizational skills
• Attention to detail
• General Typing Skills at 45wpm
• Proficiency in English with an aptitude for spelling and grammar
• Exemplary planning and time management skills
• Ability to work in high pressure, deadline driven environment
• Ability to multitask and prioritize daily workload
• High level verbal and written communications skills
• Discretion and confidentiality
• Demonstrated ability to problem solve complex, multifaceted, situations
• Ability to engage easily in abstract thought
• Strong organizational and task prioritization skills

Education / Experience:

• Degree in Nursing from an accredited college
• Required to have education, training or professional experience in medical and/or clinical practice
• A current license, without restrictions (RN or LVN)
• 3-5 years of clinical nursing experience (Preferred)
• Prior experience in Utilization Management (Preferred)

License and Certification:

Current RN or LVN licensure, without restrictions

Disclaimer:

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of our personnel. All Nexus employees may be required to perform duties outside of their normal responsibilities from time to time, as needed.