Registered Nurse - US Tech Solutions, Inc.
Columbia, SC 29229
About the Job
Job Description:
- Schedule- Mon-Fri- 8:30am EST to 5pm EST. Microsoft Teams interview with two department members. 1-week onsite training.
- We would sign on the computer at 8:30am and check the workload and begin prioritizing the day. The faxes come in electronically and we get requests via phone as well. We would check for date of service or due date to determine the priority of our cases. Then we review the requests against the policy and the member’s contract. When reviewing the clinical we determine if it can be reviewed at our level. If not, then it would be sent for review with our medical director.
- Team consists of 12 members.
- Assists with health management activities/programs. Provides health coaching or intervention telephonically or reviews and evaluates medical or behavioural 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 and claims knowledge/analysis 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, chronic illness, or acute illness. Utilizes available resources to promote quality, cost effective outcomes.
- Performs medical or behavioural review/authorization process. Ensures coverage for appropriate services within benefit and medical necessity guidelines. Assesses service needs, develops and coordinates action plans in cooperation with members, monitors services and implements plans. Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions. May initiate/coordinate discharge planning or alternative treatment plans as necessary and appropriate. Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits.
- 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 is not 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. Serves as member advocate through continued communication and education.
- 3 years-healthcare program management, utilization review, or clinical experience in defined specialty. Specialty areas are oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopaedic, general medicine/surgery.
- Ability to work independently, prioritize effectively, and make sound decisions. Good judgment skills.
- Ability to persuade, negotiate, or influence others. Analytical or critical thinking skills. Ability to handle confidential or sensitive information with discretion.
- 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.
- Employee may work from one's/out of one's home.
- May involve some travel within one's community.
- Associate degree - Nursing or Graduate of Accredited School of Nursing
Source : US Tech Solutions, Inc.