Description
Our high end client is currently seeking an experienced Registered Nurse (RN) for a fully remote, contract-based, non-clinical utilization management role. This position calls for meticulous knowledge and practice in inpatient and outpatient medical procedures, excluding radiology and home health. The ideal candidate will exhibit a deep understanding and experience with Medicare Advantage programs. Additionally, you will be expected to proficiently handle pre-certification, prior authorization, and pre-service tasks, often referred to as case management or care management.
Responsibilities
- Utilize specialized knowledge on Local Coverage Determinations (LCD), National Coverage Determinations (NCD), Milliman Criteria (MCG), and InterQual in guiding decision-making processes.
- Execute prior authorizations according to medical necessity and plan coverage guidelines.
- Coordinate and perform case management across the continuum of care using a person-focused, Medicare Advantage model.
- Manage acuity system operations, ensuring accuracy and completeness of data.
- Communicate effectively with healthcare professionals to facilitate patient care.
- Administer administrative responsibilities related to patient management and care.
- Formulate patient treatment plans based on results from risk identification and analysis.
Requirements
- Active RN licensure (required)
- Solid background in inpatient and outpatient medical procedures (excluding radiology and home health)
- Medicare Advantage experience (required)
- Familiarity with terminologies such as Local Coverage Determinations (LCD), National Coverage Determinations (NCD), Milliman Criteria (MCG), and InterQual.
- Experience with acuity systems will be an added advantage.
- Excellent communication skills and strong clinical judgement.
We are looking for a dedicated Registered Nurse who is seeking a diverse and challenging role. If your experience aligns with the above requirements and you are enthusiastic about this unique opportunity, we encourage you to apply.
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All applicants applying for U.S. job openings must be legally authorized to work in the United States. Benefits are available to contract/temporary professionals, including medical, vision, dental, and life and disability insurance. Hired contract/temporary professionals are also eligible to enroll in our company 401(k) plan. Visit
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