Registered Nurses

Yoh Services LLC; Philadelphia (Philadelphia County); On-site; USD 44,000 - 62,000; Full time

Benefits offered by this job

Medical, Prescription, Dental & Vision

HSA

Life & Disability Insurance

401K Retirement Savings Plan

Direct Deposit & weekly epayroll

Referral Bonus Programs

Certification and training

Job summary

Yoh Services LLC is seeking a remote UM case management professional for a contract opportunity supporting a Philadelphia-based insurance client. The role reviews medical records to determine medical necessity, communicates with providers, and ensures regulatory compliance while acting as a patient advocate.

Candidates must reside in PA/DE/NJ tri-state area and hold PA RN licensure or Nurse Licensure Compact. Schedule is Mon-Fri, 8:45am-5pm, with 9/14 to 12/14 term and pay $32–$45 per hour, DOE.

Qualifications

• Current, active Pennsylvania Registered Nurse licensure.
• UM experience in outpatient or inpatient settings.
• Ability to determine medical necessity using established criteria.

Responsibilities

• Review medical records to determine medical necessity for services.
• Communicate with providers to clarify treatment plans and medical need.
• Ensure regulatory compliance and appropriate utilization management.
• Coordinate with case management staff and Medical Director as needed.
• Document all actions accurately in the care management system.
• Meet regulatory turnaround times and productivity goals.

Skills

RN licensure

UM experience

Regulatory knowledge

Clinical decision making

Job description

Registered needed for a REMOTE contract opportunity with Yoh’s insurance client located in Philadelphia, PA.

This candidate reviews medical records to assess members' clinical conditions and determine medical necessity for services using independent judgment and established criteria. They obtain additional clinical information from providers as needed, approve medically necessary services, elevate non-qualifying cases to the Medical Director, ensure regulatory compliance, and serve as a patient advocate and resource for navigating the healthcare system.

• Candidate must reside in the tri-state area (PA, DE, NJ)
• Candidate must have an active PA license or a Nurse Licensure Compact to include PA
• Candidate must have UM experience either in Outpatient setting (PT/OT) or Inpatient setting (bariatric or surgical elective procedures)

Schedule: Monday-Friday 8:45a-5p

Duration: 9/14-12/14 with possible extension or direct placement

Pay: $32-45/hr, DOE

What You’ll Be Doing:

• Applies critical thinking and judgement skills based on advanced medical knowledge to cases utilizing specified resources and guidelines to make case determination. Utilizes resources such as; InterQual, Care Management Policy, Medical Policy and Electronic Desk References to determine the medical appropriateness of the proposed plan.
• Utilizes the medical criteria of InterQual and/or Medical Policy to establish the need for inpatient, continued stay and length of stay, procedures and ancillary services.
• Contacts servicing providers regarding treatment plans/plan of care and clarifies medical need for services.
• Reviews treatment plans/plan of care with provider for requested services/procedures, inpatient admissions or continued stay, clarifying medical information with provider if needed
• Identifies and refers cases in which the plan of care/services are not meeting established criteria to the Medical Director for further evaluation determination.
• Performs early identification of members to evaluate discharge planning needs.
• Collaborates with case management staff or physician to determine alternative setting at times and provide support to facilitate discharge to the most appropriate setting.
• Reports potential utilization issues or trends to designated manager and recommendations for improvement.
• Appropriately refers cases to the Quality Management Department and/or Care Management and Coordination Manager when indicated to include delays in care.
• Appropriately refers cases to Case and Disease Management.
• Ensures request is covered within the member’s benefit plan.
• Ensures utilization decisions are compliant with state, federal and accreditation regulations.
• Meets or exceeds regulatory turnaround time and departmental productivity goals when processing referral/authorization requests.
• Ensures that all key functions are documented via Care Management and Coordination Policy.
• Maintains the integrity of the system information by timely, accurate data entry.

What You Need to Bring to the Table:

• Current, active, and unrestricted Pennsylvania Registered Nurse licensure.
• Three years any of combination of clinical, case management and/or disease/condition management experience.
• UM experience either in Outpatient setting (PT/OT) or Inpatient setting (bariatric or surgical elective procedures)
• Minimum of three (3) years of acute care clinical experience in a hospital or other health care setting.
• Prior discharge planning and/or utilization management experience is desirable.
• Medical management/precertification experience preferred.

Estimated Min Rate: $32.00

Estimated Max Rate: $45.00

What’s In It for You?

Benefits include:

• Medical, Prescription, Dental & Vision Benefits (for employees working 20+ hours per week)
• Health Savings Account (HSA) (for employees working 20+ hours per week)
• Life & Disability Insurance (for employees working 20+ hours per week)
• MetLife Voluntary Benefits
• Employee Assistance Program (EAP)
• 401K Retirement Savings Plan
• Direct Deposit & weekly epayroll
• Referral Bonus Programs
• Certification and training opportunities

Note: Any pay ranges displayed are estimations. Actual pay is determined by an applicant's experience, technical expertise, and other qualifications as listed in the job description. All qualified applicants are welcome to apply.

Yoh, a Day & Zimmermann company, is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

Visit https://www.yoh.com/applicants-with-disabilities to contact us if you are an individual with a disability and require accommodation in the application process.

For California applicants, qualified applicants with arrest or conviction records will be considered for employment in accordance with the Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act. All of the material job duties described in this posting are job duties for which a criminal history may have a direct, adverse, and negative relationship potentially resulting in the withdrawal of a conditional offer of employment.

It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.

By applying and submitting your resume, you authorize Yoh to review and reformat your resume to meet Yoh’s hiring clients’ preferences. To learn more about Yoh’s privacy practices, please see our Candidate Privacy Notice: https://www.yoh.com/privacy-notice