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Job Responsibilities: RN Clinical Review Coordinator – Remote – Critical Care/ LTAC

Salary: 96000 per YEAR

Company: Optum

Location: Nashville, TN 37202 US

Primary Responsibilities:

  • Researches member benefits and eligibility
  • Completes all assigned cases within required timeframes (TAT)
  • Processes and documents all case activities per SOPs and DES
  • Prepares and documents clinical case review and assigns to Medical Director for Medical Director (LTAC AIR and SNF) decision
  • Approves SNF cases where RN’s clinical review indicates that member’s condition meets clinical criteria.
  • Approves SNF cases where an LPN’s clinical review indicates that member’s condition meets clinical criteria
  • Communicates and documents Medical Director determinations to providers and members;
  • Maintains communications with providers for continuity of care and completion of ALOC requests
  • Prepares case information for assignment to National Letter Team
  • Submits requested Contract Exceptions for SNF cases
  • Educates providers members and internal staff on guidelines member benefits alternate levels of care available
  • Acts as a clinical resource to LPNs and Non-Clinical staff
  • Collaborates with other internal stakeholder’s/departments for member’s appropriate level of care: Medical Director Optum/United Nursing Home members Appeals and Grievances National Letter team and Intake/CDU
  • Performs self-audits to assure compliance with SOP DES
  • Works within HSR InterQual and/or MCG multiple SharePoint sites
  • Participates in compliance meetings process improvement planning
  • Reports individual case concerns to the manager Medical Director as needed
  • Triage cases received from IPC
  • Assign cases to Facility ICM or other work groups

Required Qualifications:

  • Registered Nurse licensed in the state of residence
  • Critical care experience or LTAC experience

Preferred Qualifications:

  • Case management certification and/or experience
  • Experience in discharge planning and/or chart review
  • Experience in acute long-term care acute rehabilitation or skilled nursing facilities
  • Experience in utilization review for an insurance company or in a managed care environment

Telecommuting Requirements:

  • Required to have a dedicated work area established that is separated from other living areas and provides information privacy with the ability to keep all company sensitive documents secure
  • Live in a location that can receive a high-speed internet connection or leverage an existing high-speed internet service

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