Nurse Reviewer - Registered Nurse
Company: Blue Cross Blue Shield of Rhode Island
Posted on: January 16, 2020
Job Description Optimize member benefits to promote effective use
of resources. Conduct pre- and post-payment review of inpatient
admissions, outpatient services, and other procedures to assess the
medical necessity and appropriateness of services on-site or
in-house. Discuss cases with attending physician and other
healthcare professionals. Prepare and refer concerns to plan
ESSENTIAL JOB FUNCTIONS:
- Conduct pre- and post-payment review of inpatient admissions,
outpatient services, and other procedures to assess the
appropriateness and continuity of care.
- Apply all aspects of the medical review function, including
pre-authorization, concurrent review, screening for quality-of-care
issues, and discharge planning. Document rationale for medical
- Identify at-risk members who would benefit from health
management programs through comprehensive health assessments.
- Monitor and evaluate patient's plan of care and identify
potential issues through telephonic outreach. Recommend appropriate
- Promote member and provider satisfaction. Provide continuity
and consistency of care by building positive relationships between
member and family, physicians, provider, care coordinator, and
healthcare plan. Represent corporation in a responsible and
- Participate in department initiatives and projects.
- Perform other duties as assigned.
Minimum Education and Experience:
- Unrestricted Rhode Island nursing license.
- Three to five years of acute medical or clinical experience or
experience in utilization review.
- Valid driver's license (on-site only).
Preferred Education, Additional Qualifications, and Experience:
- Bachelor's degree in Nursing.
- Certified Case Management certification, Certified Professional
Utilization Review certification.
- Experience working in a managed care/health maintenance
Required Knowledge, Skills, and/or Abilities:
- Understanding of utilization review techniques, including all
aspects of the medical review function, including
pre-authorization, concurrent review, and discharge planning.
- Understanding of healthcare delivery system access points and
- Correct application of healthcare management guidelines.
- Ability to navigate the healthcare delivery system.
- Advanced analytical skills with the ability to interpret and
synthesize complex data sets.
- Good business acumen and political savvy.
- Knowledge of business process-improvement techniques and
- Excellent verbal and written communication skills.
- Negotiation skills.
- Presentation skills.
- Decision-making skills
- Good problem-solving skills.
- Ability to interface with employees at all levels.
- Ability to effectively navigate ambiguous situations with
- Excellent organizational skills and ability to successfully
prioritize multiple tasks.
- Ability to handle multiple priorities/projects.
At Blue Cross & Blue Shield of Rhode Island (BCBSRI), diversity and
inclusion are central to our core values and strengthen our ability
to meet the challenges of today's healthcare industry. BCBSRI is an
equal opportunity, affirmative action employer. We provide equal
opportunities without regard to race, color, religion, age,
national origin or ancestry, disability, veteran status, sexual
orientation, genetic information, sex, gender identity or
expression, and any other personal attributes protected by federal,
state, or local law. For more information about our commitment to
diversity and inclusion, please see our Diversity Report at
The law requires an employer to post notices describing the Federal
laws prohibiting job discrimination based on race, color, sex,
national origin, religion, age, equal pay, disability, veteran
status, sexual orientation, and genetic information and gender
identity or expression. Please visit
view the "EEO is the Law" poster.
BCBSRI is committed to working with and providing reasonable
accommodation to individuals with disabilities. If, because of a
disability, you need a reasonable accommodation for any part of our
application process, please contact us at (see application details)
During the application process, please allow a minimum of five
business days before you contact our office to inquire about the
status of your application. If you have any questions regarding
your application or during the process, please contact Human
Resources by phone at (see application details) or by email at (see
application details) .
Southern New England, Boston, MA, Hartford, CT, Health Data
Analyst, RI Health Insurer, Healthcare, Wellness, Provider,
Network, Rhode Island, RI, Care Management, Certified Professional
Healthcare Management, CPHM, Certified Case Manager, CCM,
Accredited Case Manager, ACM, Utilization Review, Med/Surg,
Med-Surg, Med Surg, Medical/Surgical, Medical-Surgical, Medical
Surgical, Registered Nurse, RN, Coordinator, Coordinate, BSN,
Bachelor's Degree in Nursing, MSN, Master's
Keywords: Blue Cross Blue Shield of Rhode Island, Providence , Nurse Reviewer - Registered Nurse, Healthcare , Providence, Rhode Island
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