Clinical Review Nurses

Vaco is hiring several Clinical Review Nurses (Hiring both RN and LPN) Location: Miramar, FL RN Pay: $33- $35/hour LPN Pay: $29 - $32/hour Monday-Friday 9a-6p

The Clinical Nurse Reviewer is responsible for evaluating medical records, ensuring appropriate care coordination, and maintaining compliance with utilization management and healthcare regulations. This role involves collaborating with healthcare providers, assessing medical necessity, and making evidence-based recommendations to facilitate high-quality patient care.

Key duties/responsibilities / accountabilities, and other duties as assigned/required · Accurately review and follow all Medical Doctor (MD) orders, ensuring service requests align with contractual agreements, policies, workflows, health plan coverage guidelines and meets medical necessity. · Assess medical necessity and service eligibility for pre- and post-service requests based on health plan-specific requirements. · Interpret and apply medical policies, benefit plans, and clinical guidelines (e.g., Medicare, Medicaid, Milliman) to determine coverage for services. · Utilize approved clinical resources and industry standards to make well-informed utilization management decisions. · Ensure network provider compliance while promoting high-quality home healthcare services. · Perform Second Level Review and process Fee-for-Service (FFS) requests, compile recommendation summaries, and submit documentation to the health plan. · Maintain clear, accurate, and complete authorization and certification records in compliance with provider network guidelines. · Communicate effectively with patients, providers and claims payers regarding authorizations, denials, and required documentation, adhering to service-level expectations. · Collaborate with health plan and/or facility case managers to ensure accurate and timely processing of discharge referrals · Escalate complex or non-compliant cases to the Internal Medical Director or Health Plan for further review per department protocols. · Ensure all cases meet regulatory requirements and adhere to contractual obligations. · Manage patient referrals to the provider network, ensuring accurate certifications and appropriate case staffing per network guidelines. · Request and verify additional clinical documentation from network providers, including updated physician orders and complete medical records. · Ensure all documentation is properly recorded in designated systems, following up on orders and outstanding cases. · Ensure compliance with daily production goals, turnaround times, and contractual agreements while handling provider, beneficiary, and health plan inquiries. · Act as a resource for providers, health plans, and referral sources, offering education on the Utilization Management Program. · Participate in on-call responsibilities, including after-hours, weekends, and holiday support as scheduled. · Engage in performance improvement initiatives, staff meetings, training sessions, and committee work to support Quality Improvement (QI) initiatives. · Maintain strict confidentiality in compliance with HIPAA, URAC, and company policies. · Monitor and report on network availability, quality concerns, and utilization trends, escalating issues to supervisors as needed. · Serves as a resource for providers, health plans, staff, and referral sources, supporting and educating them on the Utilization Management Program. · Participates in on-call, after-hours, weekend, and holiday support as scheduled. · Engages in performance improvement activities, staffing meetings, training sessions, and committee work to support the Quality Improvement (QI) Program and other department or company initiatives. · Maintains strict confidentiality of patient information in accordance with HIPAA and company policies and procedures. · Monitors and reports on network availability, quality concerns, and utilization trends, escalating issues to the supervisor, as necessary.

Qualifications:

• Required: Active Licensed Practical Nurse (LPN) or Registered Nurse (RN) license in the state of Florida, and compact license.
• Minimum 2-3 years of clinical nursing experience, preferably in home health, case management, utilization review, or a managed care setting.
• Experience with medical necessity determinations based on Medicare, Medicaid, and commercial health plan guidelines.
• Strong knowledge of clinical guidelines (e.g., Milliman, InterQual, CMS policies).
• Excellent critical thinking and decision-making skills in reviewing medical documentation and determining coverage eligibility.
• Strong communication and collaboration skills to interact effectively with healthcare providers, patients, and internal teams.
• Ability to work independently while managing high-volume case reviews within required timeframes
• Detail-oriented with excellent organizational and time management skills
• Understanding of HIPAA regulations and patient confidentiality policies.
• Bachelor’s Degree in Nursing (BSN) or a related healthcare field.

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Determining compensation for this role (and others) at Vaco/Highspring depends upon a wide array of factors including but not limited to the individual’s skill sets, experience and training, licensure and certifications, office location and other geographic considerations, as well as other business and organizational needs. With that said, as required by local law in geographies that require salary range disclosure, Vaco/Highspring notes the salary range for the role is noted in this job posting. The individual may also be eligible for discretionary bonuses, and can participate in medical, dental, and vision benefits as well as the company’s 401(k) retirement plan. By submitting to this position, you are agreeing to be included in our talent pool for future hiring for similarly qualified positions.