Clinical Nurse Coordinator
Part Time JVHL Allen Park, MI Job Details Part-time $28
$34 an hour 8 hours ago Benefits Paid time off 401(k) matching Qualifications Nursing RN License Pre-authorization review for utilization management Utilization management NCQA standards Resource utilization in healthcare

Nursing Full Job Description Job Purpose:

The Clinical Nurse Coordinator is a state licensed Registered Nurse that provides management oversight in implementing the Utilization Management (UM) department functions, including prior authorization decisions and retrospective reviews for nonpatient laboratory services.

Roles and Responsibilities:

Provide leadership in the design and implementation of UM policies, processes, and procedures
Ensure quality of UM services and that contractual and regulatory requirements remain compliant through daily supervision of assigned utilization management team and required reporting.
Maintain knowledge of regulatory and accreditation agencies and related delegated requirements pertinent to case management, such as BCN Medical Policy and NCQA
Oversee the review of quality concerns identified through the QI process and the implementation and monitoring of corrective action plans
Conducts clinical reviews of authorized approval and denial recommendations from JVHL Prior Authorization Specialist for prior and retro authorizations
Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care for member
Collects, documents, and maintains all member clinical information accurately in health management systems to ensure compliance with regulatory guidelines
Provides training to Utilization Management team to promote high quality care to members & clients
Resolves or facilitates resolution of the highest risk and/or complex prior authorization issues
Identify opportunities to create efficiencies in the UM program and activities, collaborate to design and implement improvements
Participate in Internal UM Committee
Comply with all JVHL policies and standards

Other Roles and Responsibilities:

Develop/maintain memberships in professional organizations
Maintain valid licensure
Contribute to other areas and perform duties at JVHL as needed
Ability to work independently and collaboratively in a fast-paced environment
Update job knowledge by participating in education opportunities
This position will require access to Patient Health Information (PHI), both electronic and hardcopy, so employee will be required to assist in its protection by following corporate policies and procedures that are designed to maintain the privacy and security of PHI.

Education/Qualifications:

Graduate from an Accredited School of Nursing or bachelor's degree in nursing and 2

4 years of related experience.

Experience in case review, utilization management and prior authorization requests

Preferred Skills:

Familiarity with clinical decision-making criteria and evidence-based guidelines used in the prior authorization process Knowledge of Medicare and Medicaid regulations Knowledge of NCQA Utilization Management processes

Job Type:

Part-time Pay:

From $28.00 per hour Expected hours: 20

25 per week

Benefits:

401(k) Paid time off

Work Location:

Hybrid remote in Allen Park, MI 48101

Job Type:

Part-time Pay:

$28.00

$34.

00 per hour

Benefits:

401(k) matching Paid time off

Work Location:

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RN - Clinical Nurse Coordinator - Part Time