Travel Nurse RN - Case Manager - $1,932 per week in Charlestown, MA

Cynet Health

Charlestown, MA

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JOB DETAILS

SALARY

$1,931.50–$1,931.50

SKILLS

Accreditation Standards, Case Management, Certified Case Manager (CCM), Communication Skills, Healthcare, Home Care, Interpersonal Skills, Medicaid, Medicare, Outpatient Care, Patient Care, Process Improvement, Registered Nurse (RN), Time Management, Utilization Management

LOCATION

Charlestown, MA

POSTED

Today

Job Title: Prior Authorization Clinician Profession: Clinical Specialty: Prior Authorization Duration: 13 weeks Shift: 8 hours Hours per Shift: 8 Experience: Minimum of 2 years prior authorization experience and knowledge of evidence-based guidelines. License: Active, unrestricted RN license in state of residence Certifications: None specified Must-Have: Knowledge of Medicare and Medicaid Description: The Prior Authorization Clinician is responsible for reviewing all proposed hospitalization, home care, and inpatient/outpatient services for medical necessity and efficiency. This role ensures members receive appropriate and timely care to support optimal health outcomes. The clinician determines the medical appropriateness of inpatient and outpatient services by evaluating medical guidelines. They apply evidenced-based criteria to make decisions. Utilization review activities include pre-certification, concurrent, and retrospective reviews. The clinician assesses medical necessity by applying the appropriate medical criteria to initial reviews. Decision-making and critical-thinking skills are essential for determining coverage for medically necessary health care services. All utilization review activities and outcomes must be documented and communicated effectively. The clinician refers cases to a Physician Reviewer when requests do not meet medical necessity guidelines. Referrals must be conducted in a timely manner according to departmental policies. Strong interpersonal and communication skills are required for conducting reviews and interactions. The clinician sends appropriate system-generated letters to providers and members. Guidance and coaching for other utilization review nurses are part of the role. The clinician participates in team meetings, educational discussions, and related activities. Compliance with all federal, state, and accreditation organizations is necessary. Opportunities for improved communication or processes should be identified. The clinician may participate in audit activities and meetings. Accurate documentation of rate negotiation is essential for proper claims adjudication. Potential cases may be identified and referred for Care Management. All other related duties may be assigned as necessary.

About the Company

Cynet Health

Cynet Health is a TJC certified MBE and one of the fastest-growing healthcare staffing firms in the US providing Health Med and Health IT staffing and consulting services to countless hospitals, SNFs, clinics, labs, CROs, health & wellness centers, pharmacies, and other medical facilities across the United States. Headquartered in Sterling, Virginia, we are a certified Minority-Owned Business Enterprise and a recognized Diversity Supplier.

COMPANY SIZE

1,000 to 1,499 employees

INDUSTRY

Healthcare Services

WEBSITE

https://cynethealth.com/