Registered Nurse-Nurse Clinician
Clinical Consultant | Chattanooga, TN | Contract
Registered Nurse – Nurse Clinician
Work Location: Chattanooga, TN
InGenesis Solutions has an exciting opportunity for an RN to join our client as a Nurse Consultant. In this role, the Nurse will perform comprehensive pre-existing reviews, reviews of rider-related diagnoses, potential misrepresentation referrals, rider related drug appeals, provider and member appeals, denial interpretation for letters, retrospective claim review, special review requests, and UM pre-certifications and appeals, utilizing medical appropriateness criteria, nursing judgement, and contractual eligibility.
Job Duties/Responsibilities/Functions (including but not limited to)
• Performs thorough research and provides complete documentation for rationale to support determinations as well as specific written instructions regarding additional information necessary to complete the review.
• Performs or participates in special studies or projects/pilots as directed by departmental management.
• Cross functional and accomplished in all ancillary review functions.
• May mentor/trains new incumbents and serve as a preceptor.
• Seeks the advice of the Medical Director when medical judgment is required.
• Initiates referrals to accomplish discharge planning when such plans are evident at the time of the request e.g., telephone request for scheduled for total hip replacement.
• Assists non-clinical staff in performance of administrative reviews.
• Interacts with Onsite and Case Management areas to ensure smooth transfer of member information across the continuum of care.
• Applies established vendor protocols for authorization processes
• Registered Nurse in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law required.
• Bachelor’s degree in nursing preferred. Experience
• Minimum 3 years varied clinical experience required
• Proficient knowledge and ability to apply various accreditation requirements (URAC, NCQA, etc.) preferred.
• Proficient in interpreting benefits, contract language specifically symptom-driven, treatment driven, look back periods, rider information and medical policy/medical review criteria preferred. Skills/Certifications
• Ability to maintain professional and courteous internal communication with various departments, particularly Claims, in the exchange of information.
• Must be PC literate with extensive knowledge of Windows and Microsoft Office. Must be able to pass Windows navigation test.
• Must possess excellent verbal and written communication skills with problem-solving abilities as well as organizational and interpersonal skills.
• Ability to work independently and handle multiple tasks.
• Ability to adapt to a high paced environment
InGenesis is dedicated to placing people in positions that preserve life, improve lives and inspire others. This does not happen without passionate people, skilled colleagues who are motivated to create innovative solutions and deliver superior service to our clients. Founded in 1998, InGenesis manages thousands of employees, including pioneering healthcare, science, technology and pharma professionals. The workforce solutions company includes almost half of the Fortune 500 in its nearly 300 clients. It is recognized as one of the largest healthcare staffing firms, and InGenesis is the largest minority/women owned healthcare staffing firm in North America.
We support a diverse workforce and is an Equal Opportunity Employer who does not discriminate against employees and applicants for employment on the basis of race, gender, color, religion, national origin, age, sexual orientation, gender identity, genetic information, disability, veteran status, or other classification protected by law.