Pre-Authorization RN - Telecommute Job-009686

Equity Staffing Group

Remote, OR, USA Remote / Work-at-Home /WFH

Jun 15

This job is no longer accepting applications.

Equity Staffing is searching for experienced Pre Authorization RN, this is a Telecommute Position. This Job is with a Fortune 100 organization. Our client serves more than 85 million people and has a reputation for bold ideas. If you enjoy working with energetic people in a collaborative environment, we want to speak with you!

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*APPLICANTS MUST BE A LICENSED RN IN THE STATE OF NEVADA*

*Position Description: *
* Collect case specific member information, review and certify the medical necessity of prospective, concurrent, and retrospective units of inpatient and outpatient services.

* Review each case and determine the most appropriate services, the most appropriate setting in which the services should be delivered, the most cost efficient methods for care of delivery, and the need for planning subsequent care for contracted members and their eligible dependents as assigned.

* Providing clinical and managed care expertise, as well as Medical Director/physician consultation.

* Provide first level clinical review for all inpatient and outpatient services requiring authorization for assigned client group regarding: Prospective Review Urgent/ Non-urgent, Concurrent Review, Retrospective Review, Early initiation of discharge coordination, Analyze case-specific patient information. Verify eligibility, as applicable, and past utilization history.

* Client-specific protocol and procedures Maximize referrals to network providers.

* Evaluation for referral to case management.

* Focused Second Surgical Opinion Review. Identifying and reporting quality of care issues. Answer telephone calls promptly as scheduled and as needed.

* Maintain working knowledge of all client groups Demonstrate adequate competence in computer software use in daily activities.

* Review case-specific patient information concurrently for the medical necessity of hospital admissions using commercial review criteria and/or scripted guidelines.

* Based on severity or complexity of the enrollees condition, ability to meet commercial review criteria and or scripted guidelines, the necessary treatment, and the discharge planning activity (not routinely conducted on a daily basis), the nurse reviewer will assign the appropriate LOS days/ visits/ services in review of the clinical information obtained. Document pertinent clinical information regarding individual reviews using department templates.

* Ensure timely notification of all parties (telephonic and/or written), as necessary, regarding certification recommendations.

* Assist in administering the second surgical opinion process.

* Handle caller requests addressed to other staff members; acts as a liaison assist the caller by routing to the appropriate person/ staff.

* Prepare case files for physician review via Physician Consultant Services or Medical director.

* This includes preparation of clinical information; correspondence.

* Function as a member of a self-directed team to meet specific individual and team performance metrics.

* Telephonic discussions with health care providers and members to explain medical necessity determinations and to obtain additional clinical information.

* Ensure consistent application of the utilization review process for all functional components.

* Document case review findings, actions, and outcomes in accordance with policy. Participate in special projects, as needed Participate in team meetings.

* Review clinical coverage reviews and assure client recommendations, as designated. Manage workload to ensure timely processing per state and federal mandates

*Qualifications include: *
* Active RN nurse licensure; minimum of 2 years clinical experience. Previous Utilization

* NV License is preferred.

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* Managed care experience is preferred, Sound clinical judgment

* Demonstrated understanding of managed care concepts

* Strong problem solving and decision making skills, Strong departmental team player

* Good written and verbal communication skills

* Personal computer skills, Strong time management and prioritization skills

* Excellent customer service skills including a sense of urgency and ownership for resolving issues

* Strong interpersonal skills at an individual and team level

* Ability to be flexible, adjust quickly and react positively to change

* Knowledge of ICD-10 and CPT coding preferred

* Considerable knowledge of principles, practices and current trends in nursing

* Positive attitude and good work ethics.

Monday - Friday 8 - 5 PST Remote.

Equity Staffing Native American owned staffing companies in the United States. We are a certified Minority Business Enterprise (MBE) by the National Minority Supplier Development Council (NMSDC) and the Rocky Mountain Minority Supplier Development Council (RMMSDC).

Equity Staffing Group is an Equal Employment Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other characteristic protected by law. Equity Staffing Group will consider qualified applicants with criminal histories in a manner consistent with the requirements of applicable law.

We welcome you to learn more about our company by visiting www.equitystaffing.com

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Job Types: Full-time, Contract

Pay: $40.00 per hour

Schedule:
* Day shift

Education:
* High school or equivalent (Preferred)

Experience:
* Utilization review: 3 years (Required)

License/Certification:
* State of Nevada RN Lecense (Required)

Work Location:
* Fully Remote
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