Managed Care - Registered Nurse

3 days ago Be among the first 25 applicants This range is provided by US Tech Solutions. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more. Base pay range $38.00/hr - $38.00/hr Duration: 4+ months (Possible contract to hire) Work Schedule: Mon- Fri (8am-5pm) Job Description: Onsite Training (Travel is covered/Reimbursed) Should expect to be in office for orientation for at least 4 weeks. Hours/Schedule: 8-4:30PM M-F and Call every 4-6 weeks once fully trained- Call will not begin for at least 3 months. Call hours are less than 6 hours per weekend assigned, there are exceptions to this and will be reviewed with Management Skill sets: Appeals and reconsideration experience, Utilization management experience, Prior experience working for a health insurance company and/or with Medicare population, Flexibility, dependability- we are often called to assist other depts. Strong analytical stills, each case is a puzzle that needs to be put together, not an a,b,c checklist. o Knowledge of MS Office (Outlook, Teams, Excel) and able to learn and work out of multiple other systems simultaneously. Ability to work independently. Self-driven to accomplish a productivity goal without constant direction Responsibilities: Reviews and evaluates medical or behavioral eligibility regarding benefits and clinical criteria by applying clinical expertise, administrative policies, and established clinical criteria to service requests or provides health management program interventions. Utilizes clinical proficiency, claims knowledge/analysis, and comprehensive knowledge of healthcare continuum to assess, plan, implement, coordinate, monitor, and evaluate medical necessity, options, and services required to support members in managing their health, chronic illness, or acute illness. Utilizes available resources to promote quality, cost effective outcomes. Provides active case management, assesses service needs, develops and coordinates action plans in cooperation with members, monitors services and implements plans, to include member goals. Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions. Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits. Provides telephonic support for members with chronic conditions, high risk pregnancy or other at-risk conditions that consist of: intensive assessment/evaluation of condition, at risk education based on members’ identified needs, provides member-centered coaching utilizing motivational interviewing techniques in combination with reflective listening and readiness to change assessment to elicit behavior change and increase member program engagement. Performs medical or behavioral review/authorization process. Ensures coverage for appropriate services within benefit and medical necessity guidelines. Utilizes allocated resources to back up review determinations. Identifies and makes referrals to appropriate staff (Medical Director, Case Manager, Preventive Services, Subrogation, Quality of care Referrals, etc.). Participates in data collection/input into system for clinical information flow and proper claims adjudication. Demonstrates compliance with all applicable legislation and guidelines for all regulatory bodies, which may include but isnot limited to ERISA, NCQA, URAC, DOI (State), and DOL (Federal). Participates in direct intervention/patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans. May identify, initiate, and participate in on-site reviews. Serves as member advocate through continued communication and education. Promotes enrollment in care management programs and/or health and disease management programs. Maintains current knowledge of contracts and network status of all service providers and applies appropriately. Assists with claims information, discussion, and/or resolution and refers to appropriate internal support areas to ensure proper processing of authorized or unauthorized services. Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members. Experience: 4 years clinical experience. Skills: Working knowledge of word processing software. Ability to work independently, prioritize effectively, and make sound decisions. Good judgment skills. Demonstrated customer service, organizational, and presentation skills. Demonstrated proficiency in spelling, punctuation, and grammar skills. Demonstrated oral and written communication skills. Ability to persuade, negotiate, or influence others. Analytical or critical thinking skills. Ability to handle confidential or sensitive information with discretion. Required Software and Tools: Microsoft Office. Preferred Skills and Abilities: Working knowledge of spreadsheet, database software. Knowledge of contract language and application. Thorough knowledge/understanding of claims/coding analysis/requirements/processes. Preferred Software and Other Tools: Working knowledge of Microsoft Excel, Access or other spreadsheet/database software. Work Environment: Typical office environment. Employee may work from one's/out of one's home. May involve some travel within one's community. Education: Associate Degree - Associate Degree - Nursing, or Graduate of Accredited School of Nursing. Required License/Certificate: Active, unrestricted RN licensure from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC) About US Tech Solutions: 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. Seniority level: Mid-Senior level Employment type: Contract Job function: Health Care Provider Industries: Insurance #J-18808-Ljbffr