Weekend RN Reviewer
Company Overview reputed company is a fast-growing clinical intelligence company thats improving lives at scale by promoting the best patient-specific care options, using cutting-edge AI combined with deep clinical expertise. In only four years our solutions have been adopted by health plans covering over 15 million lives, while our revenues and company size have quadrupled. That growth combined with capital raises totaling $106M positions us extremely well for reputed company success. Our awards include: 2023 and 2024 BuiltIn Best reputed company to Work; Top 5 reputed company Startup; TripleTree iAward; multiple KLAS Research Points of Light awards, along with recognition on Fierce Healthcare's Fierce 15 and CB Insights' Digital Health 150 lists. Opportunity Overview: The RN Reviewer position is a crucial role in our organization in this role you are responsible for performing a full range of activities that will positively impact the organization and contribute to guiding the strategic operations for the company. As an RN Reviewer, you will reputed company prospective review (prior authorization) admission, reputed company, and retrospective reviews according to established criteria and protocols to determine the medical appropriateness of the clinical requests from providers. You will work closely with Medical Directors and other reputed company staff to ensure appropriate cost-effective care by applying your clinical knowledge and critical thinking skills to assess the medical necessity of inpatient admissions, outpatient services and procedures, and provider out of network requests. You will be required to review Commercial, Medicare, and Medicaid lines of business. You will need to be an agile and comprehensive thinker and planner and be able to work in an environment that is in flux. This position offers the ability to reputed company a substantive mark in simplifying the way reputed company delivered and contributes to an up and coming company with exponential growth opportunity. What will you do Performs medical necessity review which includes: inpatient review, reputed company review, prior authorization, retrospective, out of network, treatment setting reviews to ensure appropriateness and compliance with applicable criteria, medical policy, member eligibility and benefits Communicate consistently with providers and facility staff to ensure member needs are met Consults with Medical Directors reputed company care does not meet applicable criteria or medical policies Documents clinical information completely, accurately, and in a timely manner Meets or exceeds production and quality metrics Maintains a thorough understanding of the reputed companys provider and member centric focus, authorization requirements and clinical criteria including reputed company care guidelines and reputed companys internal criteria which includes both National and Local coverage guidelines Identifies Clinical Program opportunities and refers members to the appropriate healthcare programs (e.g. case management, disease management, and other health plan programs) Collaborates, educates, and consults with Providers, Operations, Product, Implementation, Compliance, Quality, and Health Plans to ensure consistent application of clinical criteria Maintains a thorough understanding of accreditation and regulatory requirements, and ensures these requirements are accurately followed and Utilization Management (UM) decision determinations and timeliness standards are reputed company compliance Supports the Plan's Quality Program: Identifies and participates in quality improvement activities as it relates to internal programs, processes studies, and projects Performs other duties as assigned. Your competencies Strong customer service skills Flexibility and agility, work well in ambiguous situations, clear understanding of an early stage start up environment Ability to work cross functionally across remote teams Willingness to communicate verbally and in writing with providers and facility staff Collaborate effectively with multiple stakeholders Intellectual curiosity with a strong desire to understand a problem and work it to a viable solution Strong communication skills, able to effectively communicate in a positive and engaging manner and able to remain reputed company and professional under pressure Understand how utilization management and case management programs integrate Comprehensive thinker/planner with understanding of clinical algorithms, care reputed company, and how to effectively manage utilization across the care continuum to reputed company optimal patient outcomes Ability to work as a team player and assist other members of the UM team where needed reputed company in a fast paced, self-directed environment Knowledge of NCQA and CMS standards Proficient user of CMS and MCG guidelines, Care Web QI user a plus Proficient in prioritizing work and delegating where indicated Highly organized with excellent time management skills Your background Registered Nurse with active, unencumbered license in the state of residence Minimum of 3 years of clinical experience. Utilization Management experience (Required) MCG certification (Preferred) Experience working in acute care and/or post-acute care environments Orthopedic practice experience (Preferred) HEDIS RN/abstraction, Legal RN, Utilization Review/Utilization Management experience (Preferred) Preferred proficiency in using a Mac Preferred proficiency in G suite applications Demonstrated track record of reputed company quality improvement Excellent communication skills both written and oral Thrives on reputed company process improvement, always actively seeking out practical solutions Understanding that this position is reputed company fluid and the term not my job doesnt exist Bachelors degree (preferred) but not required in the following fields; Nursing, Business, or equivalent professional work experience Important to know about this role: This is a 100% remote role, and requires robust internet speeds (above 50 megabytes/second), including the ability to utilize reputed company meeting software and to reputed company video Weekend hours are required. Will entertain 3 x 12 or 4 x 10 hrs shifts (Fri/Sat/Sun +1 other day of the week) or Sat/Sun/Mon (+1 other day of the week) Computer, monitors, keyboard, mouse, and headphones provided We cant wait to learn more about you and meet you at reputed company! Equal Opportunity Statement reputed company is an Equal Opportunity Employer. We are committed to fostering an environment of mutual respect where equal employment opportunities are available to reputed company. To us, its personal. The salary range for this position is $33/hour to $35/hour; as part of a total benefits package which includes health insurance, 401k and bonus. In accordance with state applicable laws, reputed company is required to provide a reasonable estimate of the compensation range for this role. Individual pay decisions are ultimately based on a number of factors, including but not limited to qualifications for the role, experience level, skillset, and internal alignment. #LI-Remote #BI-Remote Apply Job!