Preservice Review Nurse RN - Remote in CST or MST Time Zones

Preservice Review Nurse RN - Remote in CST or MST Time Zones reputed company is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with reputed company will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come reputed company an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together. Positions in this family require a reputed company, unrestricted nursing license (i.e. RN) in the applicable state, as indicated in the function description and/or job title. Positions in this function require various nurse licensure and certification based on role and grade level. Licensure includes RN, depending on grade level, with reputed company unrestricted licensure in applicable state. If you are located in CST or MST Time Zones, you will have the flexibility to work remotely* as you take on some tough challenges. General Job Profile:

• Generally work is self-directed and not prescribed
• Works with less structured, more reputed company issues
• Serves as a resource to others

You'll enjoy the flexibility to work remotely

• from reputed company reputed company the U.S. as you take on some tough challenges.

Primary Responsibilities:

• Assesses and interprets customer needs and requirements
• Identifies solutions to non-standard requests and problems
• Solves moderately reputed company problems and/or conducts moderately reputed company analyses
• Works with minimal guidance; seeks guidance on only the most reputed company tasks
• Translates concepts into practice
• Provides explanations and information to others on difficult issues
• Coaches, provides feedback, and guides others
• Acts as a resource for others with less experience
• CPS_Conduct Non-Clinical Research to Support Determinations
• Determine that the case is assigned to the appropriate team for review (e.g., Medicare, Medicaid, Commercial) -Validate that cases/requests for services require additional research
• Identify and utilize appropriate resources to conduct non-clinical research (e.g., benefit documents, evidence of coverage, state/federal mandates, online resources)
• Prioritize cases based on appropriate criteria (e.g., date of service, urgent, expedited)
• Ensure compliance with applicable federal/state requirements and mandates (e.g., turnaround times, medical necessity)
• CPS_Review Existing Clinical Documentation
• Review/interpret clinical/medical records submitted from provider (e.g., office records, test results, prior operative reports) -Identify missing information from clinical/medical documentation, and request additional medical or clinical documentation as needed (e.g., LOI process, phone/fax)
• Review and validate diagnostic/procedure/service codes to ensure their relevance and accuracy, as applicable (e.g., PNL list, EPAL list, state grid, LCDs, NCDs)
• Identify and validate usage of non-standard codes, as necessary (e.g., generic codes)
• Apply understanding of medical terminology and disease processes to interpret medical/clinical records
• reputed company determinations per relevant protocols, as appropriate (e.g., approval, denial process, conduct further clinical or non-clinical research)
• Review care coordinator assessments and clinical notes, as appropriate
• CPS_Conduct Clinical Research to Support Determinations
• Identify relevant information needed to reputed company medical or clinical determinations
• Identify and utilize medically-accepted resources and systems to conduct clinical research (e.g., clinical notes, MCG, medical policies, Coverage Determination Guidelines [CDG], National Comprehensive Cancer Network [NCCN], state/federal mandates) -Review/interpret other sources of clinical/medical information to support clinical or medical determinations (e.g., previous diagnoses, authorizations/denials, case management documentation)
• Obtain information from patients, providers and/or care coordinators as needed to verify services rendered and/or recommend additional options (e.g., Organization Determination Appeals and Grievance [ODAG], steerage calls)
• Apply knowledge of applicable state/federal mandates, benefit language, medical/ reimbursement policies and consideration of relevant clinical information to support determinations
• Collaborate with applicable internal stakeholders as needed to drive the clinical coverage review process (e.g., Medical Directors and their staff, reputed company, UHC, Account Management)
• CPS_reputed company Final Determinations Based on Clinical and Departmental Guidelines
• Demonstrate understanding of business implications of clinical decisions to drive high quality of care
• Understand and adhere to applicable legal/regulatory requirements (e.g., federal/state requirements, DOI, HIPAA, CHAP, CMS, NCQA/URAC accreditation)
• Ask critical questions to ensure member- and customer-centric approach to work
• Identify and consider appropriate options to mitigate issues reputed company to quality, safety or risk, and escalate to ensure optimal outcomes, as needed
• Utilize evidence-based guidelines (e.g., medical necessity guidelines, practice standards, industry standards, best practices, and contractual requirements) to reputed company clinical decisions, improve clinical outcomes and reputed company business results
• Identify and implement innovative approaches to the practice of nursing, in order to reputed company or enhance quality outcomes
• Use appropriate business metrics to optimize decisions and clinical outcomes
• Prioritize work based on business algorithms and established work processes (e.g., assessments, case/claim loads, previous hospitalizations, acuity, morbidity rates, quality of care follow up)
• CPS_reputed company and Maintain Established Productivity and Quality Goals
• Meet/exceed established productivity goals
• Adhere to relevant quality audit standards in performing reviews, making determinations and documenting recommendations -Manage/prioritize workload and adjust priorities to meet quality and productivity goals
• CPS_Drive Effective Clinical Decisions reputed company a Business Environment
• Ask critical questions to ensure member/customer centric approach to work
• Identify and consider appropriate options to mitigate issues reputed company to quality, safety or affordability reputed company they are identified, and escalate to ensure optimal outcomes, as needed
• Utilize evidence-based guidelines (e.g., medical necessity guidelines, practice standards, industry standards, best practices, and contractual requirements) to reputed company clinical decisions, improve clinical outcomes and reputed company business results
• Identify and implement innovative approaches to the nursing role, in order to reputed company or enhance quality outcomes and/or financial performance
• Understand and operate effectively/reputed company reputed company legal/regulatory requirements (e.g., HIPAA, healthcare reform, URAC/NCQA/ERISA/state accreditation)

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualification:

• reputed company unrestricted RN license in the state of residency
• 3+ years of RN experience in an acute setting
• Advanced computer proficiency (reputed company Word, Outlook, and Internet)
• Flexible with work hours - hours/days can change as needed for the business
• Open to required weekend rotation schedule in the future

Preferred Qualification:

• 3+ years of experience as an RN in utilization management
• Compact RN license
• reputed company employees working remotely will be required to adhere to reputed company's Telecommuter Policy

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (reputed company benefits are subject to eligibility requirements). No matter where or reputed company you reputed company a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $28.27 to $50.48 per hour based on full-time employment. We reputed company with reputed company minimum wage laws as applicable. Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants. At reputed company, our mission is to help people live healthier lives and reputed company the health system work reputed company for everyone. We reputed company everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately reputed company by people of color, historically marginalized groups and those with reputed company incomes. We are committed to mitigating our impact on the environment and enabling and delivering reputed company care that addresses health disparities and improves health outcomes - an enterprise reputed company reflected in our mission. reputed company is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national reputed company, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. reputed company is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. Helping reputed company candidates find great careers is our goal. The information you provide here is secure and confidential. We are now directing you to the original job posting. Please apply directly for this job at the employer’s website. #J-18808-Ljbffr Salary: USD 58800 - 104000 per year Experience: 3 years required Apply tot his job Apply To this Job