Job Description
Our high end client is currently seeking an experienced Registered Nurse (RN) for a fully remote, contract-based, non-clinical utilization management role. This position calls for meticulous knowledge and practice in inpatient and outpatient medical procedures, excluding radiology and home health. The ideal candidate will exhibit a deep understanding and experience with Medicare Advantage programs. Additionally, you will be expected to proficiently handle pre-certification, prior authorization, and pre-service tasks, often referred to as case management or care management.
Responsibilities:
• Utilize specialized knowledge on Local Coverage Determinations (LCD), National Coverage Determinations (NCD), Milliman Criteria (MCG), and InterQual in guiding decision-making processes. • Execute prior authorizations according to medical necessity and plan coverage guidelines. • Coordinate and perform case management across the continuum of care using a person-focused, Medicare Advantage model. • Manage acuity system operations, ensuring accuracy and completeness of data. • Communicate effectively with healthcare professionals to facilitate patient care. • Administer administrative responsibilities related to patient management and care. • Formulate patient treatment plans based on results from risk identification and analysis.
• Active RN licensure (required)
• Solid background in inpatient and outpatient medical procedures (excluding radiology and home health)
• Medicare Advantage experience (required)
• Familiarity with terminologies such as Local Coverage Determinations (LCD), National Coverage Determinations (NCD), Milliman Criteria (MCG), and InterQual.
• Experience with acuity systems will be an added advantage.
• Excellent communication skills and strong clinical judgement.
We are looking for a dedicated Registered Nurse who is seeking a diverse and challenging role. If your experience aligns with the above requirements and you are enthusiastic about this unique opportunity, we encourage you to apply.
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