Remote RN: Medical Management & Utilization Specialist

SCAN Health Insurance; United States; À distance; USD 62 000 - 69 000; Plein temps

Avantages offerts par ce poste

Remote Work Mode

Excellent 401(k) Retirement SavingPlan

Résumé du poste

SCAN Health Insurance in the United States is seeking a Medical Management Specialist-RN to promote quality and cost-effective care under regulatory guidelines. Working under the Clinical Supervisor, the RN supports utilization management and case management for complex medical needs.

Responsibilities include ensuring appropriate care, applying evidence-based criteria, escalating to Medical Director, coordinating with the care team, and aiding transitions back into SCAN's network.

Qualifications

• Nursing degree required.
• Current and active California RN is required.
• CPUM or CPUR certification preferred, or willing to attain with 2 years.
• 3+ years of experience in medical-surgical nursing.
• 3+ years of Utilization Management/Prior Authorization experience in a Managed Care setting.
• Knowledge of California managed care industry (Medicare/Medi-Cal).
• Knowledge of Federal and State healthcare mandates and regulations.
• Health plan and vendor contracting knowledge.
• Proficient in Microsoft Word, Excel, Outlook, and PowerPoint.
• Strong analytic and problem-solving skills.
• Strong verbal and written communication skills.
• Ability to multitask and collaborate with department RNs.
• Ability to thrive in a fast-paced environment.
• ICD-9, HCPCS and CPT coding knowledge.

Responsabilités

• Ensure appropriate inpatient/outpatient care for SCAN members.
• Issue determinations within regulatory timeframes.
• Apply evidence-based criteria and guidelines to ensure necessary services.
• Escalate requests to Medical Director for non-conforming cases.
• Manage complex medical cases using case management and utilization management.
• Prepare case presentations and participate in IDT meetings.
• Assist members with urgent/emergent care needs within and outside the network.
• Coordinate transitions back into the SCAN network.
• Facilitate safe discharges and communicate needs to care team.
• Maintain documentation per policies and procedures.

Connaissances

Verbal communication

Written communication

MS Office

Analytical skills

Multitasking

Formation

Nursing degree

California RN license

CPUM/CPUR certification

Outils

Microsoft Word

Excel

Outlook

PowerPoint

Description du poste

SCAN Health Insurance in the United States is seeking a Medical Management Specialist-RN to promote quality and cost-effective care under regulatory guidelines. Working under the Clinical Supervisor, the RN supports utilization management and case management for complex medical needs.

Responsibilities include ensuring appropriate care, applying evidence-based criteria, escalating to Medical Director, coordinating with the care team, and aiding transitions back into SCAN's network.