Clinical Program Nurse

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.

• 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.

• 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.

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Why Crawford?

Because a claim is more than a number — it’s a person, a child, a friend. It’s anyone who looks to Crawford on their worst days. And by helping to restore their lives, we are helping to restore our community – one claim at a time.

At Crawford, employees are empowered to grow, emboldened to act and inspired to innovate. Our industry-leading team pioneers new solutions for the industries and customers we serve. We’re looking for the next generation of leaders to take this journey with us.

We hail from more than 70 countries and speak dozens of languages, reflecting the global fabric of the audience we serve. Though our reach is vast, we proudly operate as One Crawford: united in purpose, vision and values. Learn more at www.crawco.com.

When you accept a job with Crawford, you become a part of the One Crawford family.

Our total compensation plans provide each of our employees with far more than just a great salary

• Pay and incentive plans that recognize performance excellence
• Benefit programs that empower financial, physical, and mental wellness
• Training programs that promote continuous learning and career progression while enhancing job performance
• Sustainability programs that give back to the communities in which we live and work
• A culture of respect, collaboration, entrepreneurial spirit and inclusion

Crawford & Company participates in E-Verify and is an Equal Opportunity Employer. M/F/D/V Crawford & Company is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at Crawford via-email, the Internet or in any form and/or method without a valid written Statement of Work in place for this position from Crawford HR/Recruitment will be deemed the sole property of Crawford. No fee will be paid in the event the candidate is hired by Crawford as a result of the referral or through other means.