CTG BEHAVIORAL HEALTH NURSE REVIEWER in Westerville, Ohio
Title: BEHAVIORAL HEALTH NURSE REVIEWER
Job Number: 17205878
Behavioral Health Nurse Reviewer
CTG is immediately hiring a Remote Behavioral Health Nurse Reviewer for a contract opportunity with our premier client in the Healthcare Payer Solutions space. The right candidate will have utilization review experience in behavioral health preferably inpatient hospitalization.
Position Title: Behavioral Health Nurse Reviewer
Job Role Duties:
The Nurse Reviewer is responsible for performing clinical reviews of medical information and quality assurance as defined by review methodologies specific to the contract for which services are being provided.
Performs precertification and retrospective medical record reviews, data collection and database entry.
Assigns case reviews by identifying the issues for review and the specialty of the physician reviewer necessary to complete the peer matched review.
Provides supporting reference documentation to the reviewer.
Applies state laws during the Quality Assurance process.
Interacts with physician reviewers.
Assists in the transcription of physician reviews by editing and formatting, as needed.
Assures that all work is completed within contractual deadlines and that all components of the completed review are present.
Delivers final product to the client per client specific contractual guidelines.
Communicates with appropriate parties regarding review (enrollee, authorized representative, health plan representative, facility and state department of insurance)
Receives requests for precertification of procedures via telephone, fax, or Web.
Utilizes clinical expertise to approve services or refer requests to a physician for review.
Oversees referrals to and from physician review.
Formats and edits approval and denial letters.
Performs retrospective chart review per contract specifications.
Prepares letters to summarize retrospective review activity
Evaluates, identifies, and reports on, quality of care issues.
Communicates with health care professionals as a liaison regarding contract specifications and escalates issues as appropriate.
Participates on quality improvement teams.
Facilitates quality improvement plan development and implementation as requested, both internally and with external customers.
Participates in the project data analysis, reporting, and feedback processes.
Associate's degree or diploma (Nursing program) required; Bachelor's degree preferred
Unrestricted RN license
3 years clinical experience in behavioral services, preferably inpatient hospitalization
1 year utilization review experience, preferably in all behavioral health levels of care
Additional Job Requirement:
Ability to communicate both verbally and in writing fluently in English.
Ability to work proficiently with Microsoft Word, Excel, and Power Point.
Ability to analyze and evaluate medical information.
Ability to provide good customer service skills.
Ability to medically review; chart audits, and quality improvement processes.
Ability to travel 10%.
Ability to sit and work at a computer for an extended period of time.
Average manual dexterity in use of a PC, phone, sorting, filing and other office machines.
Ability to perform well in team environment, with staff at all levels, to achieve business goals.
Ability to function under pressure and with deadline oriented project demands as well as manage multiple initiatives.
Ability to apply existing knowledge of health care marketplace including commercial and government insurance health plan organizations and HIPAA guidelines with their associated security requirements.
Ability to work independently to meet predefined production and quality standards· Working knowledge in and successful application of basic level of health care data analysis and clinical review.
Writes articles for newsletters as requested and participates in provider training as needed.
Ability to travel 10%
If interested, please immediately apply to this requisition. For additional information please contact Sara Wade at email@example.com or call 716-882-8000 x 4908.
CTG is the most reliable IT services provider, built on 50 years of meeting our commitments to make technology work for clients and deliver real business value. CTG provides industry-specific IT strategy, services, and solutions that address the business needs and staffing challenges of clients in high-growth industries, including major technology companies, large corporations, and government entities located in North America and Western Europe.
CTG's greatest asset is its people, and as such we are committed to providing employees programs and processes to support their performance, hone their skills, and advance in their careers. This commitment is reflected by CTG being named a Best Places to Work Company by Modern Healthcare (since 2013) in North America, and a Best Places to Work Company in the United Kingdom (2013), Belgium (since 2007), and Luxembourg (since 2011).
CTG will consider for employment all qualified applicants including those with criminal histories in a manner consistent with the requirements of all applicable local, state, and federal laws.
CTG is an Equal Opportunity/Affirmative Action Employer and strong advocate of workforce diversity. Minority/Female/Sexual Orientation/Gender Identity/Disability/Veteran.
Job: Health Payer