Remote Utilization Review RN — Contract

HealthEdge Software, Inc.; Idaho; A distancia; USD 55.000 - 61.000; A tiempo parcial

Descripción de la vacante

HealthEdge Software, Inc. is seeking a motivated Utilization Review RN to perform prospective, concurrent, and retrospective review of inpatient and outpatient services to ensure medical necessity and appropriate level of care.

This role involves coordinating discharge planning and addressing appeals initiated by providers, facilities, and members. The position emphasizes reviewing authorization requests, applying clinical criteria, and collaborating with internal/external teams across time

Formación

• Registered Nurse with current unrestricted RN 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.

Responsabilidades

• Review, research and authorize requests for authorization of elective, direct, ancillary, urgent, emergency, etc. services.
• Analyze, research, respond to and prepare documentation related to retrospective review requests and appeals in accordance with local, state and federal regulatory and designated accreditation standards.
• Establish, coordinate, and communicate 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.

Conocimientos

Written and verbal communication

Customer service

Interpersonal skills

MS Office

Clinical criteria application

Knowledge of medical procedures

Policies and benefits knowledge

Educación

Registered Nurse license

Case Management certification (preferred)

2+ years clinical experience

Descripción del empleo

HealthEdge Software, Inc. is seeking a motivated Utilization Review RN to perform prospective, concurrent, and retrospective review of inpatient and outpatient services to ensure medical necessity and appropriate level of care.

This role involves coordinating discharge planning and addressing appeals initiated by providers, facilities, and members. The position emphasizes reviewing authorization requests, applying clinical criteria, and collaborating with internal/external teams across time