Registered Nurse
US Tech Solutions, Inc.
Columbia, SC
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JOB DETAILS
SALARY
$34–$34 Per Hour
JOB TYPE
Temporary, Contractor, Full-time
SKILLS
Academic Intervention, Adjudication, Administrative Policies, Analysis Skills, Behavioral Health, Cardiology, Case Management, Chronic Disease, Clinical Competency, Clinical Data Collection, Clinical Information, Clinical Study Publications, Clinical Support, Communication Skills, Compensation and Benefits, Customer Support/Service, Data Entry, Discharge Plans, Disease Prevention and Control, ERISA (Employee Retirement Income Security Act of 1974), Establish Priorities, Healthcare, Healthcare Providers, Intravenous Therapies, Maintenance Services, Medical Writing, Medicare, Medicine, Member Orientation, National Committee for Quality Assurance (NCQA), Needs Assessment, Negotiation Skills, Neonatology, Network Systems, Nursing Credentials, Oncology, Organizational Skills, Orthopedics, Patient Care Authorizations, Patient Education, Persuasion Skills, Presentation/Verbal Skills, Psychiatry and Mental Health, Quality Management, Quality of Care, Registered Nurse (RN), Resource Management, Subrogation, Time Management, Utilization Management, Utilization Review Accreditation Commission (URAC), Word Processing, Writing Skills
LOCATION
Columbia, SC
POSTED
21 days ago
Job Description:
- Training - will last upto six weeks but could be extended.
- Training will be conducted onsite for at least four weeks with the potential to complete the remaining training remotely.
- The candidates are able to complete training onsite if required for the entire duration.
- Utilization management experience and /or Appeals experience /strong clinical skills Behavioral Health or infusion therapy experience.
- A typical day would like in this role: Process prior authorization requests for Medicare Advantage line of business.
- Previous Medicare experience and /or UR experience/Process Appeals requests/can have experience in either Utilization management or Appeals.
- Ability to process authorization requests in timely fashion/ must communicate with team members to facilitate movement of authorization requests/ must have strong written clinical skills.
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.
- 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 is not limited to ERISA, NCQA, URAC, DOI (State), and DOL (Federal).
- Provides discharge planning and assesses service needs in cooperation with providers and facilities. 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. Collaborates with Care Management and other areas to ensure proper care management processes are executed within a timely manner.
- Manages assigned members and authorizations through appropriate communication. Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members. 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. 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.
Experience:
- 4 years recent clinical in defined specialty area. Specialty areas include: oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, general medicine/surgery.
Skills:
- Working knowledge of word processing software.
- Knowledge of quality improvement processes and demonstrated ability with these activities.
- Knowledge 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.
- 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.
Education:
Associate Degree - Nursing, or Graduate of Accredited School of Nursing.
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 www.ustechsolutions.com.
US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity,
national origin, disability, or status as a protected veteran.
About the Company
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