Rn Jobs

About The Position

Requirements

• Licensed Registered Nurse (RN) in the state of Kentucky, in good standing with no disciplinary action.
• 1+ year of utilization management experience.
• Maintain compliance with state regulations and organizational standards, ensuring that we coordinate and document member discharge plans and communicate them.
• Experience performing initial and concurrent reviews for medical service requests, with the ability to interpret clinical criteria and apply judgment to support appropriate use and benefit administration.
• Experience engaging with providers and care teams through telephonic, virtual, or onsite interactions to facilitate authorizations and support member-centered discharge planning.
• Strong proficiency in Microsoft Office Suite, including Word, Excel, and PowerPoint.
• Must reside in Kentucky or a county that is within contiguous bordering states.
• Self-provided internet service must meet at least a download speed of 25 Mbps and an upload speed of 10 Mbps; wireless, wired cable or DSL connection is suggested.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Nice To Haves

• 2+ years of progressive clinical experience in an acute care, skilled nursing, or rehabilitation setting.
• Bachelor's degree in nursing.
• MCG experience.
• Experience in discharge planning, transitions of care, and familiarity with community-based resources and social determinants of health.
• Health plan experience.
• Medicaid experience.
• Bilingual in English and another language.

Responsibilities

• Performing medical necessity reviews, including initial and concurrent authorization decisions, using established clinical criteria and independent clinical judgment.
• Facilitating comprehensive, proactive, and barrier-focused discharge planning to home or a lower level of care.
• Interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members.
• Coordinating and communicating with providers, members, or other parties to facilitate optimal care and treatment.
• Maintaining compliance with state regulations and organizational standards for coordinated member discharge, ensuring all plans are documented and communicated effectively.
• Performing initial and concurrent reviews with medical necessity determinations, including level of care and length of stay decisions.
• Engaging providers via telephonic, virtual, and onsite collaboration as needed.
• Following established guidelines/procedures.

Benefits

• medical
• dental
• vision benefits
• 401(k) retirement savings plan
• time off (including paid time off, company and personal holidays, paid parental and caregiver leave)
• short-term and long-term disability
• life insurance