registered nurse - , SC, United States - US Tech Solutions, Inc.

Description

• Work Hours: 8:30am-5pm, Monday-Friday.


• One interview with 2 supervisors/managers; takes about 45 min.


• UM and/or appeals experience.


• We want to see all candidates with experience with prior insurance, utilization management, case management, surgical or behavioural health experience. This role conducts reviews of previously denied services to determine if the medical necessity and contract provisions have been applied correctly or if newly submitted information would change the determination.

• Researches the substance of complex appeal or retrospective review requests including pre-pay and post-payment review appeal requests. Provides thorough clinical review or benefit analysis to determine if the requested services meet medical necessity guidelines.


• Documents decisions within mandated timeframes and in compliance with applicable regulations or standards. Documents the basis of the appeal or retrospective review in an accurate and timely manner and in accordance with applicable regulations or standards.


• Performs thorough research of the substance of service appeals by both member and provider based on clinical documentation, contractual requirements, governing agencies, policies, and procedures, while adhering to confidentiality regulations regarding protected health information.


• Performs appeal and retrospective reviews demonstrating ability to define and determine precedence of pertinent issues in application of policies and procedures to clinical information and or application to benefit or policy provisions. Performs special projects including reviews of clinical information to identify quality of care issues.

• 2 years clinical experience plus 1 year utilization/medical review, quality assurance, or home health, OR 3 years clinical.

• Working knowledge of word processing software. Working knowledge of managed care and various forms of health care delivery systems. Strong clinical experience to include home health, rehabilitation, and/or broad medical surgical experience.


• Knowledge of specific criteria/protocol sets and the use of the same. Ability to handle confidential or sensitive information with discretion.


• Microsoft Office. Knowledge of statistical principles. Knowledge of National Committee for Quality Assurance (NCAG). Knowledge of Utilization Review Accreditation Commission (URAC). Knowledge of South Carolina Department of Insurance (SCDOI). Knowledge of US DOL and Health Insurance Portability/Accountability Act (HIPAA) standards/regulations. Excellent organizational and time management skills. Knowledge of claims systems. Presentation skills.


• Ability to effectively use Microsoft Office applications, such as Word, Power point and Excel. Work Environment: Typical office environment. Deadline driven environment.

• Associate Degree - Nursing or Graduate of Accredited School of Nursing.