Description:
Will this role be fully remote?: Yes
Are there any specific locations/specific states the candidates should be in?:
Must have an Ohio RN or Compact State License
Is there potential for this to extend past 6 months and/or convert to an FTE?: Unlikely at this time.
Requirement:
BH experience required. Must be licensed in OH or have a compact license.
WORK SCHEDULE:
Monday thru Friday 8:00AM to 5:00PM EST (Rotating weekends and Holiday schedules are required for this position.)
Once orientation period has finished, Employee may be eligible for an alternative work schedule.
Summary:
- Works with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and other utilization management activities aimed at providing *** members with the right care at the right place at the right time.
- Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review.
- Assesses services for Client Members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
Essential Functions:
- Provides concurrent review and prior authorizations (as needed) according to Client policy for Client members as part of the Utilization Management team.
- Identifies appropriate benefits, eligibility, and expected length of stay for members requesting treatments and/or procedures.
- Participates in interdepartmental integration and collaboration to enhance the continuity of care for Client members including Behavioral Health and Long Term Care.
- Maintains department productivity and quality measures.
- Attends regular staff meetings.
- Assists with mentoring of new team members.
- Completes assigned work plan objectives and projects on a timely basis.
- Maintains professional relationships with provider community and internal and external customers.
- Conducts self in a professional manner at all times.
- Maintains cooperative and effective workplace relationships and adheres to company Code of Conduct.
- Consults with and refers cases to Client medical directors regularly, as necessary. Complies with required workplace safety standards.
Knowledge/Skills/Abilities:
- Demonstrated ability to communicate, problem solve, and work effectively with people. Excellent organizational skill with the ability to manage multiple priorities.
- Work independently and handle multiple projects simultaneously. Knowledge of applicable state, and federal regulations.
- In depth knowledge of Interqual and other references for length of stay and medical necessity determinations.
- Experience with NCQA.
- Ability to take initiative and see tasks to completion.
- Computer Literate (Microsoft Office Products).
- Excellent verbal and written communication skills.
- Ability to abide by Clients policies.
- Ability to maintain attendance to support required quality and quantity of work.
- Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA).
- Skilled at establishing and maintaining positive and effective work relationships with coworkers, clients, members, providers and customers.
Required Education:
- Completion of an accredited Registered Nursing program. (a combination of experience and education will be considered in lieu of Registered Nursing degree).
Required Experience:
- Minimum 0-2 years of clinical practice.
- Preferably hospital nursing, utilization management, and/or case management.
Required Licensure/Certification:
Active, unrestricted State Nursing (RN, LVN, LPN) license in good standing.