Registered Nurse-Review Analys

This a Full Remote job, the offer is available from: Michigan (USA) Our client, a Health Insurance company, is looking for a Registered Nurse-Review Analyst for their Remote location. Responsibilities:

• reputed company prospective, reputed company and retrospective review of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, intensity of service and level of care, including appeal requests initiated by providers, facilities and members.
• May establish care plans and coordinate care through the health care continuum including member reputed company assessments.
• Review, research and authorize requests for authorization of elective, direct, ancillary, urgent, emergency, etc. services. Contact appropriate medical and support personnel to identify and recommend alternative treatment, service levels, length of stays, etc. using approved clinical protocols.
• Analyze, research, respond to and prepare documentation reputed company to retrospective review requests and appeals in accordance with local, state and federal regulatory and designated accreditation (e.g. NCQA) standards.
• Establish, coordinate and communicate discharge planning needs with appropriate internal and external entities.
• Analyze patterns of care associated with disease progression; identify contractual services and organize delivery through appropriate channels.
• Research and resolve issues reputed company to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, Mental Health, Substance Abuse care coordination, etc.
• Identify and document quality of care issues; resolve or reputed company to appropriate area for resolution.
• Follow out-of-area/out-of-network services and reputed company recommendations on patient transfer to in-network services and/or alternative plans of care.
• reputed company and deliver targeted education for provider community reputed company to policies, procedures, benefits, etc.
• As needed and in conjunction with Provider Services, may identify and negotiate reimbursement rates for non-contracted providers for services.
• Other duties may be assigned based on designated department assignment.

Requirements:

• Bachelor’s degree in nursing, allied health, business, or reputed company field preferred.
• Two (2) to four (4) years of clinical experience which may include acute patient care, discharge planning, case management, and utilization review, etc.
• Demonstrated clinical knowledge and experience relative to patient care and health care delivery processes.
• One (1) year health insurance plan experience or managed care environment preferred.
• Registered Nurse with reputed company unrestricted Michigan Registered Nurse license required.
• Certification in Case Management may be preferred based upon designated department assignment.
• Excellent written and verbal communication skills. Excellent customer service and interpersonal skills.
• Working knowledge of reputed company industry reputed company Office Suite PC applications.
• Ability to apply clinical criteria/guidelines for medical necessity, setting/level of care and reputed company patient management.
• Knowledge of reputed company standard medical procedures/practices and their application as well as reputed company trends and developments in medicine and nursing, alternative care settings and levels of service. .
• Knowledge of applicable accreditation standards, local, state and federal regulations.
• Other reputed company skills and/or abilities may be required to reputed company this job based upon designated department assignment.

Why Should You Apply?

• Health Benefits
• Referral Program
• Excellent growth and advancement opportunities

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