Remote RN Review Analyst

Job Title: Remote RN Review Analyst

About Kyyba:

Founded in 1998 and headquartered in Farmington Hills, MI, Kyyba has a global presence delivering high-quality resources and top-notch recruiting services, enabling businesses to effectively respond to organizational changes and technological advances.

At Kyyba, the overall well-being of our employees and their families is important to us. We are proud of our work culture which embodies our core values; incorporating value, passion, excellence, empowerment, and happiness creates a vibrant and productive atmosphere. We empower our employees with the resources, incentives, and flexibility that they need to support a healthy, balanced, and fulfilling career by providing many valuable benefits and a balanced compensation structure combined with career development.

Position Details:

Job Title: Remote RN Case Manager

Location: 100% Remote

Duration: 12+ Months

License Required: Michigan State RN License

Local candidates only, as there may be an occasional requirement for onsite meetings.

SUMMARY

Perform prospective, concurrent and retrospective review of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, intensity of service and level of care, including appeal requests initiated by providers, facilities and members. May establish care plans and coordinate care through the health care continuum, including member outreach assessments.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.

1. Review, research and authorize requests for authorization of elective, direct, ancillary, urgent, emergency, etc. services. Contact appropriate medical and support personnel to identify and recommend alternative treatment, service levels, length of stays, etc. using approved clinical protocols.

2. Analyze, research, respond to and prepare documentation related to retrospective review requests and appeals in accordance with local, state and federal regulatory and designated accreditation (e.g. NCQA) standards.

3. Establish, coordinate and communicate discharge planning needs with appropriate internal and external entities.

4. Analyze patterns of care associated with disease progression; identify contractual services and organize delivery through appropriate channels.

5. Research and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, Mental Health, Substance Abuse care coordination, etc.

6. Identify and document quality of care issues; resolve or route to appropriate area for resolution.

7. Follow out-of-area/out-of-network services and make recommendations on patient transfer to in-network services and/or alternative plans of care.

8. Develop and deliver targeted education for provider community related to policies, procedures, benefits, etc.

9. As needed and in conjunction with Provider Services, may identify and negotiate reimbursement rates for non-contracted providers for services.

10. Other duties may be assigned based on designated department assignment.

EDUCATION AND EXPERIENCE

1. Bachelor’s degree in nursing, allied health, business, or related field preferred.

2. Two (2) to four (4) years of clinical experience which may include acute patient care, discharge planning, case management, and utilization review, etc.

3. Demonstrated clinical knowledge and experience relative to patient care and health care delivery processes.

4. One (1) year health insurance plan experience or managed care environment preferred.

CERTIFICATES, LICENSES, REGISTRATIONS

1. Registered Nurse with current unrestricted Michigan Registered Nurse license required.

2. Certification in Case Management may be preferred based upon designated department assignment.

QUALIFICATIONS

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

OTHER SKILLS AND ABILITIES

1. Excellent written and verbal communication skills. Excellent customer service and interpersonal skills.

2. Working knowledge of current industry Microsoft Office Suite PC applications.

3. Ability to apply clinical criteria/guidelines for medical necessity, setting/level of care and concurrent patient management.

4. Knowledge of current standard medical procedures/practices and their application as well as current trends and developments in medicine and nursing, alternative care settings and levels of service. .

5. Knowledge of applicable accreditation standards, local, state and federal regulations.

6. Other related skills and/or abilities may be required to perform this job based upon designated department assignment.

ADDITIONAL INFORMATION

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified. This job description does not constitute a contract for employment.

Location: Remote (Detroit, MI)

Page Range Where Required (currently California, Colorado, New York, Washington)

Disclaimer:

Kyyba is an Equal Opportunity Employer.

Kyyba does not discriminate on the basis of race, religion, color, sex, gender identity, sexual orientation, age, non-disqualifying physical or mental disability, national origin, veteran status or any other basis covered by appropriate law. Minorities / Females / Protected Veterans / Individuals with Disabilities are encouraged to apply. All employment is decided on the basis of qualifications, merit, and business need.

It is the policy of Kyyba to provide reasonable accommodation when requested by a qualified applicant or employee with a disability, unless such accommodation would cause an undue hardship. The policy regarding requests for reasonable accommodation applies to all aspects of employment, including the application process. If reasonable accommodation is needed, please contact Kyyba at View phone number on click.appcast.io.

Rewards:

Medical, dental, vision

401k

Term life

Voluntary life and disability insurance

Optional Pre-paid legal plan

Optional Identity theft plan

Optional Medical and dependent FSA

Work-visa sponsorship

Opportunity for advancement

Long-term assignment with opportunity for hire by client

SELECT AWARDS

· An INC 5000 company for 10 years

· Corp! Michigan Economic Bright Spots

· Crain’s Detroit Business Top Staffing Service Companies in Detroit

· TechServe Alliance Excellence Award- IT and Engineering Staffing & Solutions

· Best of MichBusiness winner in HR Wizards & Partnerships

· Metro Detroit Elite Category: Recruitment, Selection & Orientation for 101 Best &

Brightest

· 101 Best & Brightest Companies to Work for in Michigan