Registered Nurse (Utilization Management) ** 100% remote **

Amerit Consulting; California; Remote; USD 90,000 - 120,000; Part time

Job summary

Amerit Consulting seeks an experienced Registered Nurse (Utilization Management) for a 6-month contract with potential extension or conversion to a full-time role. This is a 100% remote position for California residents with standard business hours (08:00 AM - 05:00 PM PT).

The ideal candidate reviews medical documents to determine the appropriate level of care, audits hospital bills for contract compliance and medical necessity, and conducts retrospective utilization reviews using

Qualifications

• Current California RN license
• At least 5 years of relevant experience
• Concurrent or post-service inpatient review experience a plus
• Microsoft Office including Teams and Outlook
• EMR experience preferred
• Independent motivation, strong work ethic, and solid computer navigation skills
• Managed care experience including inpatient claims or concurrent review preferred

Responsibilities

• Review medical documents to determine the most appropriate level of care
• Audit hospital itemized bills for contract compliance, medical necessity, and proper billing
• Perform retrospective utilization reviews using evidence-based guidelines
• Present cases to Medical Director for oversight and determinations
• Communicate determinations to providers and members in compliance with regulations
• Identify potential quality of care issues and delays and intervene as appropriate
• Review coding logic using industry standards and CMS guidelines
• Triages and prioritizes cases to meet turnaround times

Skills

RN license

5+ years experience

EMR experience

MS Office (Teams/Outlook)

Managed care experience

Strong computer navigation

Tools

MS Teams

Outlook

Job description

Our client, a mutual benefit corporation and health plan provider, seeks an accomplished Registered Nurse (Utilization Management).

*** Candidate must be authorized to work in USA without requiring sponsorship ***

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*** Location: 100% Remote for California Residents

*** Duration: 6 months contract w/ possibility of extension or conversion to FTE role

Notes

• Work Hours: 08:00 AM - 05:00 PM Pacific Time.
• This is a 100% remote position.
• Employees must reside and perform their work within the State of California throughout employment.

Description

• The Facility Compliance Review team reviews post service prepayment facility claims for contract compliance, industry billing standards, medical necessity, and hospital acquired conditions/never events.
• The Utilization Management Nurse, Senior will report to the Senior Manager, Facility Compliance Review.
• In this role you will be reviewing medical documents and applying clinical criteria to establish the most appropriate level of care.
• Also, you will be reviewing hospital itemized bills for a comprehensive line-by-line audit and manual claims processing on exceptions to ensure that appropriate billing practices are followed based on facility specific contract language. These exceptions may include medical necessity, DRG validation, stop loss, trauma, ER, burns, implants, NICU, transplants, hospital acquired conditions/never events and aberrant billing.
• Perform retrospective utilization reviews and first level determination approvals for members using evidenced based guidelines, policies and nationally recognized clinal criteria across lines of business or for a specific line of business such as Medicare and FEP.
• Conducts clinical review of claims for medical necessity, coding accuracy, medical policy compliance, and contract compliance.
• Prepare and present cases to Medical Director (MD) for medical director oversight and necessity determination and communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements.
• Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards and identify potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate.
• Clearly communicates, is collaborative, while working effectively and efficiently.
• Review itemizations for coding logic using industry standards as well as CMS guidelines.
• Triages and prioritizes cases to meet required turn-around times.
• Identifies potential quality of care issues, service, or treatment delays as clinically appropriate.
• Clinical judgment and detailed knowledge of benefit plans used to complete review decisions.

Qualifications

• Requires a current California RN License.
• Requires at least 5 years of prior relevant experience.
• Concurrent or post service inpatient review experience is nice to have.
• Microsoft Office including Teams, Outlook.
• Previous EMR experience preferred.
• Requires independent motivation, strong work ethic, and strong computer navigations skills.
• Previous managed care experience including inpatient claims or concurrent review preferred.

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Company Overview

Amerit Consulting is an extremely fast-growing staffing and consulting firm. Amerit Consulting was founded in 2002 to provide consulting, temporary staffing, direct hire, and payrolling services to Fortune 500 companies nationally, as well as small to mid-sized organizations on a local & regional level. Currently, Amerit has over 2,000 employees in 47 states. We develop and implement solutions that help our clients operate more efficiently, deliver greater customer satisfaction, and see a positive impact on their bottom line. We create value by bringing together the right people to achieve results. Our clients and employees say they choose to work with Amerit because of how we work with them - with service that exceeds the expectations and a personal commitment to their success. Our deep expertise in human capital management has fueled our expansion into direct hire placements, temporary staffing, contract placements, and additional staffing and consulting services that propel our clients’ businesses forward.

Amerit Consulting provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

Applicants, with criminal histories, are considered in a manner that is consistent with local, state, and federal laws.