Clinical Program Nurse

Position is responsible for the clinical oversight of the Physician Review Services coordination team, assuring compliance with jurisdictional and stand-alone-client requirements.

The nurse will focus on contributing to the appropriateness and effectiveness of clinical products and programs developed by and/or supported by the Medical Department.

In addition, the nurse will be a liaison to the other medical management departments.


* Bachelor of Science in Nursing or related clinical degree preferred.

Must hold an RN License


* 5 + years of clinical nursing


* Managed care experience


* Basic office equipment (copy machine, scanning, fax)


* Microsoft Office, Teams


* Articulate oral communication


* Professional written communication


* Organizational /management skills


* Clinical guidelines and criteria


* Evidence-based-medicine


* Individuals who conduct initial clinical review must possess a current, professional license or certification in good standing and without restrictions with the home state:
+ To practice as a health professional in a state or territory of the U.S.; and
+ With a scope of practice that is relevant to the clinical area(s) addressed in the initial clinical review.


* Must complete continuing education requirements as outlined by Crawford Educational Services.

#LI-RG1


* Assists with managing the Physician Review Services (PRS) coordination team operations.

Acts as a resource for interpreting clinical scenarios and assists in the determination of assignment to the appropriate clinical specialty for peer reviews.


* Assists with onboarding of physicians to physician peer review panel to include collaborative training on the PRS system and access to evidenced based guidelines.


* Monitors and documents case activities in a timely manner.


* Reviews member's medical record and medical aspects of claim while applying critical thinking to various clinical scenarios.


* Interprets & applies appropriate clinical criteria when making clinical decisions or refers to appropriate physician peer reviewer to determine appropriate treatment and level of care.


* Addresses customer inquiries/concerns regarding clinical issues within PRS and stand-alone business reviews/reports.


* Participates in the QI Committee and QI project as assigned/necessary.


* May perform other duties as assigned.