Nurse RN 3

Nurse RN 3

Duration: 6+ months | Possible extension (Contract to Hire/ Temp to Perm)

Shift: 8am to 5pm PST Monday - Friday.

Location: Remote CA

PR: XXXX-48.00/hr

Day-to-day responsibilities:

• Perform prospective, concurrent, and retrospective utilization reviews and first level determination approvals for members using CMS evidenced based guidelines, policies and nationally recognized clinical criteria for the Medicare line of business.
• Ensure discharge planning at appropriate levels of care for the members' needs and acuity.
• Durable medical equipment, and post service needs to ensure quality and cost-appropriate DC planning.
• Prepare and present cases to Medical Director for oversight/necessity determination and communicate determinations to providers and members to comply with state, federal and accreditation requirements.
• Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards.
• Identify potential quality of care issues, service, or treatment delays, and intervene as clinically appropriate.
• Refer to Case Management when there are acute inpatient needs affecting discharge.
• Attend staff meetings, clinical rounds, and weekly huddles.
• Maintain quality and productivity metrics for all casework.
• Maintaining HIPAA compliant workspace for telework environment.

Education Requirement:

• Associate's degree in nursing required. Bachelor's degree preferred.
• CA Nursing license required.
• Minimum of 5 years of experience in the inpatient hospital setting is required

Skills:

• Verbal communication skills, attention to detail, and problem-solving skills.
• Self-driven, able to work independently
• Strong clinical background and critical thinking skills
• Able to multitask while prioritizing cases to meet regulatory and business needs

Software Skills Required:

• Windows, excel, and outlook.

Disqualifiers/ Dislikes on Resumes:

• No Clinical experience. Many Short-term Jobs without explanation.