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815572b2661b912b6384c7826218a708

Registered Nurse

Spectraforce Technologies Inc Rancho Cordova, CA Full-Time
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What we do?

SPECTRAFORCE is an award winning global staffing, IT services and consulting company that specializes in providing top talent and solutions for clients throughout North America and India. We pride ourselves on our partnership with our clients, MSP/VMS providers, and our employees, who have enabled us to continually be ranked as a Top Supplier in the 75+ different clients we support.


Job Title: Transplant Case Management – RN
Job Duration: 6+ months
Job location: Rancho Cordova, CA 95670

Day to Day Responsibilities of this Position and Description of Project:

  • Working with complex cases promotes the delivery of quality; cost-effective health care services based on medical necessity and contractual benefits.
  • Works with other members of HCS team, provider, hospitals, IPA/MGs, members and their families to plan and review medical necessity, intensity of services, level of care, length of stay and general appropriateness of care.
  • Provides guidance to the provider network. Performs effective discharge planning and collaborates with member support system and health care professionals involved in the continuum of care.
  • Will provide case management to member segments with chronic/ catastrophic illness and/or transplant candidates and recipients.
  • Ability to speak with and conduct clinical review with medical directors, including concurrent review and prior authorization requests. Ability to work with Prior Auth, and other nursing teams to include Appeals & Grievance.
  • Ability to read and comprehend clinical documentation.
  • 2+ years of UM health plan/ IPA/Med Group experience, prior authorization and concurrent review required.
  • Previous health insurance experience, insurance/payer knowledge.
  • Clinical experience – oncology, ICU, CM, and/or transplant. Transplant experience preferred.


Education and Credentials

  • Current, Active, Unrestricted California Registered Nurse License required.
  • Certified Case Manager (CCM) preferred or obtained within two years of hire.
  • Bachelor’s/Master’s – Nursing or Health Services Administration.

Recommended skills

Appeals
Certified Case Manager
Insurance
Prior Authorization
Registered Nurse Certified
Intensive Care Unit
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