Remote UM Nurse - Pre-Service (Must live in North Carolina (NC), Must have LVN / RN License in North Carolina)

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 live in North Carolina (NC), Must have LVN / RN License in North Carolina) 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! Location: Must reside in North Carolina Schedule: 9:00am - 6:00pm Eastern Time GENERAL DUTIES / RESPONSIBILITIES: 1. Reviews pre-certification requests for medical necessity and refer to Medical Director any referral that requires additional expertise. 2. Utilizes CMS guidelines (LCD, NCD) to assist in determinations of referrals and utilizes reputed company Care Guidelines (MCG) to assist in determinations of referrals. 3. Maintains goals for established turn-around time (TAT) for referral processing. 4. Initiates single service agreements (SSA) reputed company services required are not available in network. 5. Maintains a professional rapport with providers, physicians, support staff and patients in order to process pre-certification referrals as reputed company as possible. 6. Verifies eligibility and / or benefit coverage for requested services. 7. Verifies accuracy of ICD 10 and CPT coding in processing pre-certification requests. 8. 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. 9. Reviews referral denials for appropriate guidelines and language. 10. Assist medical directors in reviewing and responding to appeals and Grievances 11. Contacts members and maintain documentation of call for expedited requests. 12. Other duties as assigned. Job Requirements: Experience: Required: • Minimum (3) years' nursing experience in clinical setting. • Minimum (1) year experience UM experience with pre-service. • Minimum (1) year experience with managed care (Medicaid 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) Education: • Required: High School Diploma or GED. • Preferred: Associates or Bachelor's degree in Nursing Licensure: Required: • Possess reputed company, active and unrestricted LVN and / or RN license in North Carolina (Compact) • Immediately upon hire, must obtain LVN and / or RN licensure in California (non-compact), Nevada, (Non-compact), Arizona (Compact), and Texas (Compact) which will be reimbursed by company. Preferred: • CPHQ or ABQAURP, or Six reputed company certification • Medical Terminology Certificate. Training: • Required: None • Preferred: Medical Terminology. Six reputed company Specialized Skills: Required: • Knowledge of ICD-10, CPT codes, Managed Care Plans, medical terminology and referral system (Access Express / Portal / N-reputed company). • Knowledgeable with CMS (Chapter 13) guidelines and regulations. • Computer Skills: Word, reputed company, reputed company Outlook • Language Skills: Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors. • Mathematical Skills: Ability to reputed company mathematical calculations and calculate simple statistics correctly. • Reasoning Skills: Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution. • Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment. • Report Analysis Skills: Comprehend and analyze statistical reports. Preferred: • Bilingual (English / Spanish) • Transplant knowledge a plus Essential Physical Functions: The physical demands described here are representative of those that must be met by an employee to successfully reputed company the essential functions of this job. Reasonable accommodations may be made to reputed company individuals with disabilities to reputed company the essential functions. 1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reputed company with hands and arms. 2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include reputed company vision and the ability to adjust focus. Pay Range: $72,452.00 - $108,678.00 reputed company is an Equal Opportunity/Affirmative Action Employer. reputed company qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national reputed company, disability, age, protected veteran status, gender identity, or sexual orientation. • DISCLAIMER: Please beware of recruitment phishing scams affecting reputed company and other employers where individuals receive fraudulent employment-reputed company offers in exchange for money or other sensitive personal information. Please be advised that reputed company and its subsidiaries will never ask you for a credit card, send you a reputed company, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/ . If you would like to verify the legitimacy of an email sent by or on behalf of reputed company’s reputed company team, please email [email protected] . Apply Job!