Remote - EST

MANAGER NOTES:

Will work 1 weekend day (saturday or sunday)
No OT - will have 1 day off during the week to total 40 hours
8 or 10 hour shift available
During Traing M-F 8-5
Hours are Eastern Time hours

Interview Process - 3 person zoom panel interview - (one and done)
30 minute interview
Possible temp to perm if role opens to perm and performance is good.

TOP SKILLS:
communication
case management skills
insurance background a plus
understanding medicare is a plus
computer skills a must, all documentation is on line
MS Office
care radius and facets software ( all day everyday)

Hiring Requirements

• RN with 3 years of clinical experience or LPN with 5 years of clinical experience.
• For Behavioral Health specific roles, other applicable licensure may be considered with a minimum of 3 years of clinical experience.
• Must have and maintain a valid and applicable clinical license (NC or compact multi-state licensure) to perform described job duties.

NO SPOTLIGHT CALL !

Clinical Evaluation and Review
• Receive assigned cases for varied member services (i.e. inpatient, outpatient, DME)
• Review and evaluate cases for medical necessity against medical policy, benefits and/or care guidelines and regulations.
• Complete work in accordance with timeliness, production, clinical quality/accuracy and compliance standards
• Provide notifications to member and/or provider, according to regulatory requirements.
• Assess appropriateness for secondary case review by the Medical Director (MD) for denials and coordinate as needed.
• May coordinate peer-to-peer review upon provider request when members’ health conditions do not meet guidelines

Collaboration and Documentation
• Communicate and collaborate effectively with internal and external clinical/non-clinical staff (including MDs) to coordinate work
• Appropriately and fully document outcome of reviews and demonstrate the ability to interpret and analyze clinical information
• Utilize detailed clinical knowledge to summarize clinical review against the criteria/guidelines to provide necessary information for MDs.

Hiring Requirements

• RN with 3 years of clinical experience or LPN with 5 years of clinical experience.
• For Behavioral Health specific roles, other applicable licensure may be considered with a minimum of 3 years of clinical experience.
• Must have and maintain a valid and applicable clinical license (NC or compact multi-state licensure) to perform described job duties.