Temporary UM RN

HealthEdge•Remote,

5d•Remote

About The Position

HealthEdge is seeking a highly motivated Utilization Review RN to conduct prospective, concurrent, and retrospective reviews of inpatient, outpatient, ambulatory, and ancillary services. The role evaluates medical necessity, appropriate length of stay, intensity of service, and level of care, including appeal requests initiated by providers, facilities, and members. Depending on the department assignment, the RN may also establish care plans and coordinate care across the health care continuum, including conducting member outreach assessments. The RN reviews and authorizes service requests, consults medical and support personnel about alternative treatment or service options, and prepares documentation for retrospective reviews and appeals in accordance with applicable regulations and accreditation standards. The position also supports discharge planning, care coordination, quality-of-care issue resolution, provider education, and recommendations concerning out-of-network care. This is a remote U.S. contract position. Work may span multiple time zones, and travel may be required depending on company needs.

Requirements

Current, unrestricted Registered Nurse license.
At least 2 years of clinical experience, which may include acute patient care, discharge planning, case management, or utilization review.
Demonstrated clinical knowledge and experience related to patient care and health care delivery processes.
Excellent written and verbal communication skills.
Excellent customer service and interpersonal skills.
Working knowledge of current Microsoft Office Suite PC applications.
Ability to apply clinical criteria and guidelines for medical necessity, setting or level of care, and concurrent patient management.
Knowledge of current standard medical procedures and practices and their application, as well as current trends and developments in medicine and nursing, alternative care settings, and levels of service.
Knowledge of policies and procedures, member benefits, and community resources.
Knowledge of applicable accreditation standards and local, state, and federal regulations.
Other related skills or abilities may be required based on department assignment.

Nice To Haves

Case Management certification may be preferred depending on department assignment; certification or progress toward certification is highly preferred and encouraged.
At least 1 year of experience with a health insurance plan or in a managed care environment is preferred.

Responsibilities

Review, research, and authorize requests for elective, direct, ancillary, urgent, emergency, and other services.
Contact appropriate medical and support personnel to identify and recommend alternative treatment, service levels, and lengths of stay using approved clinical protocols.
Analyze, research, respond to, and prepare documentation for retrospective review requests and appeals in accordance with local, state, and federal regulations and designated accreditation standards, such as NCQA.
Establish, coordinate, and communicate discharge planning needs with appropriate internal and external entities.
Analyze patterns of care associated with disease progression; identify contractual services and organize their delivery through appropriate channels.
Research and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, and care coordination.
Identify and document quality-of-care issues and resolve them or route them to the appropriate area.
Follow out-of-area and out-of-network services and recommend patient transfers to in-network services or alternative plans of care.
Develop and deliver targeted education for the provider community about policies, procedures, and benefits.
As needed and in conjunction with Provider Services, identify and negotiate reimbursement rates for non-contracted providers.
Perform other duties as assigned based on department assignment.