Nurse Reviewer

Company: Alicare Medical Management ( Learn More )

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General Information
US-NH-Manchester
N/A
2 Year Degree
Full-Time
5 to 10 years
Not Specified
False
False
Job Description Alicare Medical Management(AMM) is an affiliate of Amalgamated Life Insurance Company, an A.M. Best's "A" rated New York life insurance company. AMM is a medical call center providing medical cost management products and services to managed care companies, commercial insurance companies, self-insured organizations, HMO's, and third party administrators nationwide. Our offices operate 24 hours a day, 7 days a week, 365 days a year. We offer an employee friendly atmosphere, terrific benefits, and the opportunity to grow and develop your career.

The Nurse Reviewer utilizes medical knowledge, established clinical guidelines, and physician support to provide medical review of care rendered to patients by providers and determine if care provided is medically necessary and appropriate.

Responsibilities:
  • Applies medical criteria guidelines to evaluate for purposes of certification, inpatient admissions and surgical procedures, outpatient psychiatric and substance abuse treatment, selected diagnostic procedures, home health services and durable medical equipment.

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  • Comprehends current accepted treatment modalities for the wide range of medical/surgical and psychiatric disorders.

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  • Participates in continuing nursing and medical education classes to assist in understanding new treatment concepts and their incorporation into current practice.

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  • Examines admission information for DRG pre-certification, certification of admissions and continued stay.

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  • Uses the computer to document and assess clinical data necessary for utilization review.

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  • Acts as liaison between various Alico departments and Medical and Utilization Review Departments regarding medical review issues.

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  • Interfaces with many levels of Alico personnel and various departments to facilitate proper adjudication of claims.

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  • Communicates with various levels of the provider system in our service area regarding utilization review issues.

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  • Reviews medical information from various out-of-area facilities for medical necessity.

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  • Communicates with hospitals, physicians and subscribers regarding certification of hospital admissions and outpatient services.

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  • Updates the Consultants on current medical review activity changes.

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  • Performs other duties and projects at the direction of Management in order to enhance the overall efficiency, effectiveness and productivity of the areas and their roles in the corporate goals.
  • Participates on an office committee.

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  • Participates in medical management review process to ensure success of the QM program and to provide quality reviews and cases.

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  • Maintains education profile.

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  • Coordinates referral of cases to the Physician Consultants: Prepares cases that require review by the Consultants.

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  • Prepares final letters dictated by the Consultants regarding the review of specific cases.
    • Job RequirementsCollege degree or nursing diploma.
    BSN or equivalent education/experience.
    Current NH RN licensure or NH license application in process if licensed in another state.
    3-5 years clinical experience in a medical/surgical setting.
    1-2 years clinical experience in a specialty setting.
    1-2 years experience in a managed care setting preferred.
    Certification in a specialty preferred.
    Knowledge of automated systems.
    Able to work with minimal supervision as a member in a team environment.
    Able to assess potential problems and formulate a solution either independently or with assistance of supervisor.
    Strong written, verbal, and interpersonal communication skills.
    Able to follow the Policy and Procedure guidelines developed by AMM for the purposes of Utilization Review, quality management, and in compliance with URAC standards.

    To apply to this position please send your resume to: [Click Here to Email Your Resumé]

    Amalgamated Life Insurance Company is an Equal Opportunity Employer.

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