Registered Nurse

Hornet Staffing, Inc, a GEE Group company; Columbia (SC); Remote; USD 60,000 - 80,000; Full time

Job summary

A leading staffing firm is seeking a Registered Nurse for a remote position requiring one week of onsite training. The role involves managing case services, reviewing health benefit eligibility, and providing member education. Candidates must possess a valid RN license and knowledge of medical reviews and health care systems. The position offers flexible work from home opportunities with potential community travel.

Qualifications

• Must be a Registered Nurse.
• Working knowledge of word processing and spreadsheet software.
• Knowledge of claims and coding analysis is preferred.

Responsibilities

• Manage case for members and coordinate service needs.
• Review medical or behavioral authorization processes.
• Educate members and providers about health care delivery.

Skills

Working knowledge of word processing software

Knowledge of claims/coding analysis

Knowledge of health care delivery system

Education

Registered Nurse license

Tools

Microsoft Office

Microsoft Excel

Microsoft Access

Job description

Overview

Must be a Registered Nurse. Remote Position but candidate must complete 1 week onsite training.

Responsibilities

• Reviews and evaluates medical or behavioral eligibility regarding benefits and clinical criteria by applying clinical expertise, administrative policies, and established clinical criteria to service requests or provides health management program interventions.
• 60% Provides active case management, assesses service needs, develops and coordinates action plans in cooperation with members, monitors services and implements plans, to include member goals. Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions.
• 20% Performs medical or behavioral review / authorization process.
• 10% Participates in direct intervention / patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans.
• 5% Maintains current knowledge of contracts and network status of all service providers and applies appropriately.
• 5% Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members.

Required Skills and Abilities

• Working knowledge of word processing software.
• Required Software and Tools: Microsoft Office.
• Preferred Skills and Abilities: Working knowledge of spreadsheet, database software. Thorough knowledge / understanding of claims / coding analysis, requirements, and processes.
• Preferred Software and Other Tools: Working knowledge of Microsoft Excel, Access, or other spreadsheet / database software.

Work Environment

• Typical office environment. Employee may work from one\'s / out of one\'s home. May involve some travel within one\'s community.