Clinical Review Nurse

  • Waterloo, IA
  • Full Time
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Job Description

Obtains physician orders, clinical notes, or other forms of medical necessity for continued services.  Works closely with patients, providers, and insurance case managers and/or claims adjusters to ensure authorization for continued services as needed, once home health care has been established. Follows each referral until the case in closed by an insurance case manager and/or claims adjuster or discharged by a physician. 


These are the responsibilities expected of an applicant interested in this position.

  • Obtain continued authorization of home health services from insurance companies
  • Contact physician’s offices, home health agencies, and patients to determine if home health services are still necessary
  • Knowledge of contract-specific guidelines
  • Excellent communication skills to keep all parties informed of order status
  • Answers questions from patients, providers, and insurance case managers and/or claims adjusters
  • Ensure orders are setup with accurate codes, quantity, and pricing
  • Complete discharge requests when services are no longer necessary
  • Review evaluations, physician orders, and progress notes from providers and facilitate the flow of information to insurance case managers and/or claims adjusters
  • Review cares and recommend cost savings and/or step down care opportunities
  • Complete weekly note reviews and 30-day summaries
  • Ensure orders are reviewed by a gatekeeper
  • Maintain thorough, up-to-date documentation on each patient in the Company’s care management platform
  • Rotation for Department on-call and back-up schedule per Department procedure
  • Provides oversight and monitors the Quality Improvement and Utilization Management activities of non-clinical staff to ensure regulatory and accreditation compliance
  • Available to monitor and support non-clinical staff
  • Follows strict confidentiality and HIPAA privacy and security guidelines
  • Knowledge of various healthcare industry billing and/or coding terminologies such as ICD-10, HCPCS, CPT, modifiers, and various Medicare LCDs
  • Any other duties as deemed appropriate by the supervisor

*Key Responsibilities do not include issuing denials of service authorization requests


Applicants are expected to meet these qualifications to be considered for this position.


  • Active Iowa RN or LPN license in good standing
  • Prefer two (2) years of experience in an acute care setting, home care setting, and/or physician office or ambulatory setting
  • Must comply with continuing education per Company, regulatory, contractual, and accreditation requirements

Key Qualifications:

  • Ability to multitask and prioritize workflow is a dynamic, fast-paced work environment
  • Possess strong time management and organization skills
  • Work well under pressure and be punctual
  • Flexible with the ability to routinely adapt to change
  • Team player with excellent communication skills
  • Maintain a courteous and professional demeanor in all customer interactions
  • Ability to learn the Company’s care management platform and adapt to any system changes
  • Knowledge of Microsoft Word, Excel, and Outlook

This job description reflects the general duties of the job but is not a detailed description of all duties which may be inherent to the position. Reasonably related additional duties may be assigned to the individual Associate.

VGM Group, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.

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