Case Review Specialist- RN req'd

Lake Success, New York, United States | 900 | Full-time

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IPRO is currently seeking a Case Review Specialist to work with IPRO’s affiliate, Lumetra.  The incumbent will be responsible for the review and processing of all requests for Independent Reviews from external agencies in accordance with contract guidelines.

This is a full-time position based in the Lake Success, NY office.

Work hours 10AM EST - 6PM EST (7AM PST - 3PM PST)

Essential Duties and Responsibilities

  • Upon receipt of the electronic medical records, communicate with contractors, providers and beneficiary/representatives.
  • Perform case reviews utilizing regulatory guidelines criteria and clinical knowledge for medical necessity and quality of care issues.
  • Formulate a case summary and the review questions for the Physician Reviewer based upon the External Agency’s concern(s).
  • Review physician determinations, ensuring all categories of concern have been addressed. 
  • Prepare written correspondences to contractors, providers and beneficiaries/representatives. 
  • Maintain contractual timeframes and URAC standards for case completion. 

Qualifications:

  • Excellent communication skills (both verbal and writing) with a professional demeanor.
  • The ability to interact with providers, internal/external customers and representatives.
  • The ability to work independently, as well as in a team environment.
  • Excellent time management/ prioritization skills to meet contractual deadlines while maintaining a high level of quality work to meet customer satisfaction and standards.
  • Strong clinical critical thinking skills.
  • Advanced skills and knowledge of standard EHR applications, office technology and Microsoft applications including Word, Excel, and PowerPoint.
  • Ability to handle sensitive and confidential information.

Education & Experience:

  •  Licensed Registered Nurse, required (open to any RN state license).
  • Graduate of a School of Nursing, required.
  • Bachelor of Science in Nursing (BSN), required
  • Three (3) years clinical experience in an acute care setting or related experience, required.
  • Experience in utilization and quality reviews, required.
  • Experience in managed care, quality management and peer review, preferred.

 

IPRO offers competitive salaries, comprehensive health and dental coverage.

IPRO is an Affirmative Action/Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status