Remote Utilization Review RN — Healthcare Innovation

Wellframe; EE. UU.; A distancia; USD 80.000 - 110.000; Jornada completa

Descripción de la vacante

HealthEdge is seeking a highly motivated Utilization Review RN to join our team. The role involves prospective, concurrent and retrospective review of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity and appropriate level of care.

Remote US-based position with potential for provider education and care coordination initiatives. The ideal candidate has an active RN license, 2+ years of clinical experience, and familiarity with health insurance plan operations.

Formación

• Registered Nurse with current, unrestricted license.
• Certification in Case Management preferred.
• Minimum 2 years clinical experience in acute care, discharge planning, case management, and utilization review.
• Demonstrated clinical knowledge of patient care and health care delivery processes.
• Minimum 1 year health insurance plan experience or managed care preferred.

Responsabilidades

• Authorize requests for elective, direct, ancillary, urgent, or emergency services.
• Research, respond to and prepare documentation for retrospective reviews and appeals.
• Coordinate discharge planning with internal and external entities.
• Analyze care patterns and coordinate services across channels.
• Resolve issues related to benefits, eligibility, and coordination of care.
• Develop targeted education for providers on policies and benefits.
• May negotiate reimbursement rates for non-contracted providers.
• Perform other duties as assigned.

Conocimientos

RN license

Case management

Clinical experience

Healthcare operations

Communication skills

Herramientas

MS Office

Descripción del empleo

HealthEdge is seeking a highly motivated Utilization Review RN to join our team. The role involves prospective, concurrent and retrospective review of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity and appropriate level of care.

Remote US-based position with potential for provider education and care coordination initiatives. The ideal candidate has an active RN license, 2+ years of clinical experience, and familiarity with health insurance plan operations.