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RN Clinical Consultant

Essential Functions and Primary Duties:

  • Perform medical necessity reviews for acute care hospitals as well as for RAC defense audits in addition to other compliance activities
  • Review cases retrospectively in order to assess adherence to medical necessity admission criteria
  • Provide analysis as to root causes for problematic situations
  • Utilize knowledge of billing and coding guidelines, as well as hospital chargemaster operations
  • Conduct medical necessity reviews utilizing both electronic medical record and hard copy record
  • Develop and conduct education for hospital clinical staff based upon reviews conducted
  • Assist in design and development of new services and products
  • Additional duties as assigned

Preferred Qualifications:

  • Proficiency in the application of InterQual Level of Care criteria is preferred
  • Knowledge of Milliman Care Guideline application, basic ICD-10 and CPT coding and CMS regulations preferred
  • Certification in Case Management or Utilization Management preferred

Qualifications Required:

  • Degreed and Licensed as a Registered Nurse (RN)
  • 3 years of nursing experience required
  • Demonstrated ability to communicate verbally and in writing throughout all levels of organization, both internally and externally
  • Proficient us of applicable technology
  • Able to travel as dictated by client
  • Ability to conduct the review of medical records for medical necessity
  • Knowledge of medical terminology, anatomy, physiology and concepts of disease
  • Knowledge of modern nursing principles, techniques and procedures for patient care



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