Remote Utilization Review RN - Case Management

HealthEdge; United States; Remote; USD 85,000 - 110,000; Full time

Job summary

HealthEdge is seeking a motivated Utilization Review RN to join our team. You will perform prospective, concurrent and retrospective reviews of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, length of stay and level of care, including appeals.

Responsibilities include authorizing requests, coordinating discharge planning, analyzing care patterns, resolving benefits issues, and educating providers on policies and benefits. This is a remote, full-time US role.

Qualifications

• Registered Nurse with current unrestricted Registered Nurse license required.
• Certification in Case Management may be preferred based upon designated department assignment. Certification or progress toward certification is highly preferred and encouraged.
• Minimum of 2 years’ clinical experience which may include acute patient care, discharge planning, case management, and utilization review, etc.
• Demonstrated clinical knowledge and experience relative to patient care and health care delivery processes.
• Minimum 1 year health insurance plan experience or managed care environment preferred.

Responsibilities

• Review, research and authorize requests for authorization of elective, direct, ancillary, urgent, emergency, etc. services.
• Coordinate discharge planning needs with appropriate internal and external entities.
• Analyze patterns of care associated with disease progression; identify contractual services and organize delivery through appropriate channels.
• Research and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, care coordination, etc.
• Identify and document quality of care issues; resolve or route to appropriate area for resolution.
• Follow out-of-area/out-of-network services and make recommendations on patient transfer to in-network services and/or alternative plans of care.
• Develop and deliver targeted education for provider community related to policies, procedures, benefits, etc.
• As needed and in conjunction with Provider Services, may identify and negotiate reimbursement rates for non-contracted providers for services.
• Other duties may be assigned based on designated department assignment.

Skills

Communication skills

Customer service

Microsoft Office

Apply clinical criteria

Healthcare knowledge

Regulatory knowledge

Education

Registered Nurse license

Tools

Microsoft Office Suite

Job description

HealthEdge is seeking a motivated Utilization Review RN to join our team. You will perform prospective, concurrent and retrospective reviews of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, length of stay and level of care, including appeals.

Responsibilities include authorizing requests, coordinating discharge planning, analyzing care patterns, resolving benefits issues, and educating providers on policies and benefits. This is a remote, full-time US role.