Nurse Reviewer (Telephonic)

Utilizes professional skills and expertise to promote high quality, cost-effective outcomes for our members. Encourages a collaborative approach among the provider community. Nurtures their personal growth and that of other staff members within the department. Perform other functions to support corporate initiatives.REPRESENTATIVE JOB DUTIES:Conduct pre and post-discharge telephonic calls to assess member’s preparedness for hospitalization, ensure a safe, effective discharge plan is in place, assessing for other health and wellness opportunities, and screening for quality of care issues.Work collaboratively with multi-disciplinary team to assist with discharge planning to promote seamless transition of care coordination. Consider the member’s medical, psychosocial, and economic needs when facilitating discharge plan.Screen cases for referral to Case Management; identify community resources, provide patient education. Responsible for implementing and tracking account specific requirements for member outreachSupport other projects and corporate initiatives as assigned.KNOWLEDGE, SKILLS & ABILITIES REQUIRED:Knowledge of:All aspects of medical review functions, regulatory compliance, and healthcare management guidelines.Discussion of cases with attending physicians and other healthcare professionals.Technical Skills:Basic computer knowledge.Strong keyboard skills.Good critical thinking and problem solving skills.Excellent verbal and written communication skills required.Strong decision making and problem solving ability as well as good organizational skills.Ability to:Handle heavy telephone volume and multiple priorities.Exercise sound judgment.Take initiative in finding solutions to difficult and/or sensitive problems.Perform other duties as assigned.QUALIFICATIONS:Minimum Education and Experience:Must have a current, unrestricted Rhode Island Nursing License.At least three years of recent clinical experience in any of the following areas; acute care, skilled nursing facility, or home care setting required. Nursing experience in any of the above areas may be combined with discharge planning experience.Preferred Education, Additional Qualifications and Experience:Demonstrated organizational skills and the ability to work independently. Health care plans and benefits. Minimum of 1 year utilization review, preferably in intake and utilization management, or managed health plan experience preferred.Proficiency in Windows, Word, Excel, AccessBCBSRI values diversity and is an Equal Employment Opportunity and Affirmative Action Employer. m/f/d/vDetailed Oriented,Excellent verbal and written communications skills,Experience with a PC,Health care knowledge,High quality of accuracy,Medical Terminology,Prior health insurance knowledge or experience,Problem solving,Registered Nurse