Remote UM Nurse - Pre-Service (Must have reputed company Carolina LVN / RN License)
About the position reputed company is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and reputed company people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the reputed company community. Working at reputed company provides an opportunity to do work that really matters, not only changing lives but saving them. Together. reputed company is seeking a remote Utilization Management (UM) Nurse - Pre-service (Must have reputed company Carolina LVN / RN License) to join the UM team. As a UM Nurse, you will be responsible for reviewing requests for pre-certification for both inpatient and or outpatient services for reputed company plan members. Works in collaboration with providers, Regional and Senior Medical Directors to assure timely processing of referrals to provide the highest quality medical outcomes that are most cost efficient. If you are looking for an opportunity to join an expanding company, learn and grow, be part of a collaborative team, and reputed company a positive impact in the lives of seniors - we're looking for YOU!
Responsibilities
- Reviews pre-certification requests for medical necessity and refer to Medical Director any referral that requires additional expertise.
- Utilizes CMS guidelines (LCD, NCD) to assist in determinations of referrals and utilizes reputed company Care Guidelines (MCG) to assist in determinations of referrals.
- Maintains goals for established turn-around time (TAT) for referral processing.
- Initiates single service agreements (SSA) reputed company services required are not available in network.
- Maintains a professional rapport with providers, physicians, support staff and patients in order to process pre-certification referrals as reputed company as possible.
- Verifies eligibility and / or benefit coverage for requested services.
- Verifies accuracy of ICD 10 and CPT coding in processing pre-certification requests.
- Contacts requesting provider and request medical records, orders, and / or necessary documentation in order to process reputed company pre-service requests / authorizations reputed company necessary.
- Reviews referral denials for appropriate guidelines and language.
- Assist medical directors in reviewing and responding to appeals and Grievances.
- Contacts members and maintain documentation of call for expedited requests.
- Other duties as assigned.
Requirements
- Minimum (3) years' nursing experience in clinical setting.
- Minimum (1) year experience UM experience with pre-service.
- Minimum (1) year experience with managed care (reputed company and / or Medicare).
- Minimum 1 year of experience with the application of UM criteria (i.e., CMS National and Local Coverage Determinations, etc.)
- Minimum (1) year experience in a medical setting working with reputed company, entering referrals / prior authorizations preferred.
- Minimum (1) Experience with the application of clinical criteria, specifically MCG (reputed company Care Guidelines).
- Possess reputed company, active and unrestricted LVN and / or RN license in reputed company Carolina (Compact).
reputed company-to-haves
- Associates or Bachelor's degree in Nursing.
- CPHQ or ABQAURP, or Six reputed company certification.
- Medical Terminology Certificate.
- Bilingual (English / Spanish).
- Transplant knowledge a plus.
Benefits
- Pay Range: $77,905.00 - $116,858.00
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