Hospital Registered Nurse #

Overview Duration: 03 Months. Location requirements: 3-4 days in Columbia to obtain computer/equipment and ensure login to applications, then remote work. Work area must be in a separate room at home with a door that remains closed/locked with no interruptions. Skill sets/qualities: Prior hospital experience. Flexibility and the ability to learn new/multiple computer systems quickly as there are multiple programs used. Prior UM and/or case management experience is preferred but not required. A typical day in this role includes inpatient admission reviews for hospitals, SNFs, rehab and LTAC facilities and continued stay reviews for these facilities. Clinicals are reviewed using Milliman & company policies. If criteria are not met, a writeup is prepared and submitted to an MD for review and a decision. Letter writing uses company templates. Communication and coordination with case management, transplant coordinators, Team Leads, medical directors and supervisors is expected. Attend quarterly and monthly meetings via Teams. Be prepared to stay in constant communication with leadership and peers via email and Teams as priorities may shift and new policies/issues may arise that require immediate acknowledgment. Responsibilities Review and evaluate medical or behavioral eligibility regarding benefits and clinical criteria by applying clinical expertise, administrative policies, and established criteria to service requests or health management program interventions. Utilize clinical proficiency and claims knowledge to assess, plan, implement, health coach, coordinate, monitor, and evaluate medical necessity and/or care plan compliance, options, and services required to support members in managing their health. Promote quality, cost-effective outcomes using available resources. Perform medical or behavioral review/authorization processes and ensure coverage for appropriate services within guidelines. Assess service needs, develop and coordinate action plans with members, monitor services, and implement plans. Evaluate outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions. Initiate/coordinate discharge planning or alternative treatment plans as necessary and appropriate. Ensure accurate documentation of clinical information to support medical necessity criteria and contract benefits. Identify and refer to appropriate staff (Medical Director, Case Manager, Preventive Services, Subrogation, Quality of Care Referrals, etc.). Participate in data collection/input into systems for clinical information flow and proper claims adjudication. Demonstrate compliance with applicable legislation and guidelines (e.g., ERISA, NCQA, URAC, DOI, DOL). Participate in direct intervention/patient education with members and providers regarding health care delivery, network utilization, and benefit plans. Serve as a member advocate through ongoing communication and education. Promote enrollment in care management and/or disease management programs. Provide telephonic support for members with chronic conditions, high-risk pregnancy, or other at-risk conditions, including intensive assessment/evaluation and member-centered coaching using motivational interviewing techniques. Maintain knowledge of contracts and network status of service providers and apply appropriately. Assist with claims information, discussion, and/or resolution and refer to appropriate internal support areas to ensure proper processing of services. Provide communications (written, telephone) regarding requested services to both health care providers and members. Qualifications & Experience Experience: 2 years’ clinical experience. Skillsets: Working knowledge of word processing software; knowledge of quality improvement processes; understanding of contract language and application. Ability to work independently, prioritize effectively, and make sound decisions; good judgment skills. Demonstrated customer service, organizational, and presentation skills; strong spelling, punctuation, and grammar; effective oral and written communication. Ability to persuade, negotiate, or influence others; analytical or critical thinking skills. Ability to handle confidential or sensitive information with discretion. Education & Licenses Education: Associate Degree - Nursing. Licenses: Active SC unrestricted RN licensure. Certifications: N/A. Shift & Work Hours Shift Hours: Monday through Friday, 8:30 AM–5:00 PM. About Us US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran. AI Statement: By applying, you acknowledge that AI-assisted tools may be used during hiring. #J-18808-Ljbffr