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.

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