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Nurse Reviewer - Registered Nurse

Company: Blue Cross Blue Shield of Rhode Island
Location: Providence
Posted on: January 16, 2020

Job Description:


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 Medical Directors.


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 decisions made.
  • 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 interventions.
  • 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 professional manner.
  • Participate in department initiatives and projects.
  • Perform other duties as assigned.
    --

    QUALIFICATIONS:
    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 organization.
        --

        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 services.
        • 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 strategies.
        • 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 limited direction.
        • 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 bcbsri.com/diversityreport .

          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 http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf to 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) for assistance.

          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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