Remote RN - Medical Necessity Specialist (9-Month Contract)

BCforward; Austin (TX); Remote; USD 48,000 - 56,000; Full time

Job summary

BCforward is seeking an RN to join our Health Clinical Services team on a 9-month contract in Austin. The ideal candidate will perform medical necessity reviews for long-term care submissions, evaluate Medicaid criteria, and provide clinical call support to providers and members by phone.

You will review documentation, render determinations with proper rationale, participate in hearings as assigned, and help escalate and resolve issues while maintaining thorough records.

Qualifications

• Unrestricted Registered Nurse license.
• High School Diploma or GED.
• Demonstrated success in team-oriented environments.
• Creative and analytical problem-solving abilities.
• Desire to work in an information systems environment.
• Excellent leadership, written and oral communication, and interpersonal skills.

Responsibilities

• Conduct medical necessity reviews for Long Term Care form submissions.
• Review and analyze clinical documentation and assessments per established criteria and protocols.
• Render determinations based on Medicaid requirements and RN training, with complete documentation and rationale.
• Participate in fair hearings as assigned and prepare supporting materials.
• Review complaints and appeals, investigate facts, and recommend dispositions.
• Provide functional telephone support, operate in the phone queue, and resolve incidents, issues, requests, and queries.
• Ensure proper documentation, notification, and escalation of contacts.
• Cross-train and assist other areas as required.
• Work an 8-hour shift between 10:00 a.m. and 7:00 p.m., local time.

Skills

Communication skills

Teamwork

Leadership

Interpersonal skills

Education

RN license

High School Diploma or GED

Tools

AWS CRM

Microsoft Office

Job description

BCforward is seeking an RN to join our Health Clinical Services team on a 9-month contract in Austin. The ideal candidate will perform medical necessity reviews for long-term care submissions, evaluate Medicaid criteria, and provide clinical call support to providers and members by phone.

You will review documentation, render determinations with proper rationale, participate in hearings as assigned, and help escalate and resolve issues while maintaining thorough records.