Icon hamburger
US
What job do you want?
Apply to this job.
Think you're the perfect candidate?
Apply Now
Thumsup

You’re being taken to an external site to apply.

Enter your email below to receive job recommendations for similar positions.
Default2

RN/Registered Nurse/LPN/Licensed Practical Nurse/ Case Manager/ Episodic Care/ Clinical Appeals/Medical

Spectraforce Durham Full-Time
Apply Now
Major Job Functions/Components


Conducts clinical reviews based on applicable medical policy and/or medical necessity guidelines on requested services.
Communicates decision to provider and/or member, according to department protocols.
Prepares, presents, and refers cases, as needed, to the physician medical directors (MDs) for cases reviewed and not meeting approval criteria.
Facilitates physician peer-to-peer contact upon provider request when members’ health conditions do not meet guidelines.
Consults with MDs when necessary and makes recommendations for alternative settings of care when appropriate.
Promotes and coordinates the delivery of quality, cost effective health care services based on medical necessity per the benefit plan.
Documents outcome of reviews and demonstrates the ability to interpret and analyze clinical information.
Utilizes detailed knowledge of clinical guidelines and policies to meet regulatory and program requirements.
Facilitates communication and information exchange among individuals involved with the care of the member such as PCP, Managing Physician, caregivers, or other ancillary services.
Communicates with providers to increase provider awareness of medical criteria and policy as it relates to services requested.
Works with providers to assure effective and efficient care management.
Meets with providers, as needed.
Coordinates care as needed for members.
Works with members and collaborates with other members of the team to enhance member navigation and access to available services through the health care system.
Identifies, assesses and facilitates discharge planning and needs.
Maintains confidentiality of all PHI in compliance with state and federal laws.

Education/Experience
RN, LPN, PA, or FNP degree with valid NC license.
For RN, PA, or FNP, 3 years previous clinical nursing experience, preferably in a variety of clinical settings, or 2 years in a health insurance related industry such as Utilization Management processes, managing health conditions, understanding medical criteria, medical guidelines, medical policy, and NCQA and DOI regulations.
If LPN, 5 years previous clinical nursing experience preferably in a variety of clinical settings, or 4 years in a health insurance related industry such as Utilization Management processes, managing health conditions, understanding medical criteria, medical guidelines, medical policy, and NCQA and DOI regulations.

Additional Education/Experience Preferences
BSN strongly preferred.
Computer experience including Word.
Knowledge of Microsoft Windows operating system.
Demonstrated commitment to high quality service to all customers.
Knowledge of medical care patterns, regulatory and governmental rules and regulations along with medical criteria and policies related to care management.
Clinical decision making skills.
Ability to embrace and accept change.
Ability to work with an interdisciplinary team is essential.

Department Specific Job Functions/Components
Health Coaching and Interventions:
May provide health coaching and education to members based on their benefit plan.
Negotiates acceptable rate for services when appropriate.

Senior Segment:
Performs database search, telephonic screening and assessment, documentation, and evaluation of clinical information to determine eligibility for DM Programs.
Identifies, facilitates, and coordinates, when appropriate, community and social services resources to compliment the physician’s treatment plan.
Demonstrates understanding of the Case Management process by consistently adhering to member privacy and confidentiality regulations, advocating for member safety and strict adherence to ethical, legal and accreditation/regulatory standards.

Recommended skills

Registered Nurse Certified
Nursing
Licensed Practical Nurse
Appeals
Utilization Management
Case Management

Location

Career Path

See the next step in your career
RN/Registered Nurse/LPN/Licensed Practical Nurse/ Case Manager/ Episodic Care/ Clinical Appeals/Medical
Estimated Salary: $77K
Apply to this job.
Think you're the perfect candidate?
Apply Now

Help us improve CareerBuilder by providing feedback about this job: Report this job

Report this Job

Once a job has been reported, we will investigate it further. If you require a response, submit your question or concern to our Trust and Site Security Team

CAREERBUILDER TIP

For your privacy and protection, when applying to a job online, never give your social security number to a prospective employer, provide credit card or bank account information, or perform any sort of monetary transaction. Learn more.

By applying to a job using CareerBuilder you are agreeing to comply with and be subject to the CareerBuilder Terms and Conditions for use of our website. To use our website, you must agree with the Terms and Conditions and both meet and comply with their provisions.

Spectraforce offers a powerful suite of Staffing and Outsourcing solutions in Information Technology, Clinical, Technical, Pharmaceutical and Engineering domains allowing companies to embrace the challenges of meeting and exceeding the company's ongoing requirements.

We enable companies to focus on their core competencies, while we handle the integral details of building infrastructure thus guaranteeing quality delivery with major cost savings. We offer a competitive edge through our unique Center of Excellence-based IT outsourcing services powered by our offshore Global Delivery capabilities.

View the full profile