The Clinical RN Specialist, PDR (Provider Dispute Resolution) Unit is responsible for performing advanced and complicated case review of the appropriateness of medical care and service provided to members requiring considerable clinical judgment, independent analysis and detailed knowledge of managed healthcare and clinical guidelines. This position identifies through retrospective review if medical necessity, quality of care and the appropriateness of the medical setting justify provider claims/appeal requests. The Clinical Nurse Specialist, PDR (Provider Dispute Resolution) Unit dotted-line reports to the Chief Medical Officer for clinical decision making.
Principal responsibilites include:
· Review, triage and prioritize cases to meet turnaround times
· Perform retrospective clinical reviews as assigned
· Acquire and review case against clinical records, clinical guidelines, policies, and EOC Benefit Policy
· Research and analyze complex issues
· Summarize cases including initial denial determination and notification, analysis of medical records and application of all applicable policies, guidelines, benefit plans and laws, and rules and regulations
· Prepare questions on complex cases for consultant review or external third party medical review (DMHC);
· Present cases to Medical Director/Chief Medical Officer for review or determination
· Develop recommendations to address member and provider disputes in a manner that is consistent with the requirements of regulatory and accrediting agencies, and supports health plan objectives;
· Develop and/or review documentation and correspondence reflecting determination
· Ensure accuracy, completeness and conformance to standards
· Interacts with members, providers and/or other staff; external to ensure resolution of plan recommendations
· Ensure communication of member or provider rights;
· Document all activities as per unit practice including entry into automated systems;
· Recognize and address potential quality care concerns
· Perform other duties and special projects as assigned.
EDUCATION OR TRAINING EQUIVALENT TO:
· Licensed Vocation Nurse or Registered Nurse license, active and unrestricted licensed in the State of California, Board certified required; and
· Bachelor's degree preferred (RN).
MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:
· Minimum three years clinical experience required;
· Three years utilization management or quality management experience strongly preferred;
· Two years of experience in appeals and grievance casework;
· Two years of experience using standardized clinical guidelines; and
· Milliman and NCQA experience preferred.
SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):
· Strong knowledge of accreditation, federal and state regulations/requirements;
· Knowledge of risk management principles;
· Ability to effectively analyze, interpret, apply and communicate policies, procedures and regulations;
· Strong analytical and problem solving skills;
· Excellent verbal and written communications skills;
· Excellent case preparation and abstracting skills;
· Team player who builds effective working relationships;
· Ability to work independently;
· Medical coding knowledge;
· Strong organizational skills; and
· Proficient in Microsoft Office suite including, Access and Project.
$77,710 - $116,570/annually