Job description

Job Title: Patient Care Specialist- UM Nurse (remote)

Start Date: 12/12

End Date: 6-month Contract/ 6-month CTH

One of our top healthcare clients is looking to build out a team of Utilization Review Nurses to support long term growth in their Medicare division.

Experience Required:

· 3+ years of Utilization Review Experience within the outpatient space

· Extensive clinical knowledge

· Experience triaging, prioritizing, and working in a high-speed work environment

· Excellent computer skills; documentation and medical records experience

· Excellent phone and communication skills

· EMR experience is a plus

· RN License preferred, LPN required

Primary Responsibilities:

· Conducts pre-certification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.

· Ensures member access to medical necessary, quality healthcare in a cost effective setting according to contract.

· Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process.

· Collaborates with providers to assess member’s needs for early identification of and proactive planning for discharge planning.

· Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications.

· Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.

Other Responsibilities:

• Responsible to collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources.
• Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of outpatient services, focused surgical and diagnostic procedures, our of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards accurately interpreting benefits and managed care products and steering members to appropriate providers, programs, or community resources.
• Works with medical directors in interpreting appropriateness of care and accurate claims payment.
• Will need to have good working knowledge of the Commercial, Medicare, and other product teams plans as they will be contacting members for updates on some occasions
• May also manage appeals for services denied.

Job Types: Full-time, Contract

Pay: $33.00 - $35.00 per hour

Benefits:

• Dental insurance
• Health insurance
• Vision insurance

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Education:

• Bachelor's (Preferred)

Experience:

• Utilization Review: 3 years (Preferred)
• Outpatient: 3 years (Preferred)
• Clinical Knowledge: 3 years (Preferred)
• Triaging and Prioritizing: 3 years (Preferred)
• Remote: 1 year (Preferred)
• EMR: 1 year (Preferred)

License/Certification:

• RN License (Preferred)
• Compact License (Preferred)

Work Location: Remote

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