Registered Nurse-Review Analys

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. 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.

Our Client, a Health Insurance company, is looking for a Registered Nurse-Review Analyst for their Detroit, MI location.
 
Responsibilities:

• 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.
• 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 and CMS regulations.
• Establish, coordinate and communicate discharge planning needs with appropriate internal and external entities.
• Analyze patterns of care associated with disease progression; identify contractual services and organize delivery through appropriate channels.
• 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.
• Identify and document quality of care issues; resolve or route to appropriate area for resolution.
• Follow out-of-area/out-of-network services and make recommendations on patient transfer to in-network services and/or alternative plans of care.
• Develop and deliver targeted education for provider community related to policies, procedures, benefits, etc.
• As needed and in conjunction with Provider Services, may identify and negotiate reimbursement rates for non-contracted providers for services.
• Other duties may be assigned based on designated department assignment.

 
Requirements:

•  Bachelor’s degree in nursing, allied health, business, or related field preferred.
• Two (2) to four (4) years of clinical experience which may include acute patient care, discharge planning, case management, and     utilization review, etc.
• Demonstrated clinical knowledge and experience relative to patient care and health care delivery processes.
• One (1) year health insurance plan experience or managed care environment preferred.
• One (1) year of utilization management preferred.
• Certificates, Licenses, Registrations
• Registered Nurse with current unrestricted Michigan Registered Nurse license required.
• Certification in Case Management may be preferred based upon designated department assignment.
• Other Skills And Abilities
• Excellent written and verbal communication skills.  Excellent customer service and interpersonal skills.
• Working knowledge of current industry Microsoft Office Suite PC applications.
• Ability to apply clinical criteria/guidelines for medical necessity, setting/level of care and concurrent patient management.
• 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.
• Knowledge of cost containment strategies, BCN/Client policies and procedures, member benefits and community resources.
• Knowledge of applicable accreditation standards, local, state and federal regulations.
• Other related skills and/or abilities may be required to perform this job based upon designated department assignment.

 
Why Should You Apply?

• Health Benefits
• Referral Program
• Excellent growth and advancement opportunities