Registered Nurse #26-21705

About the role

Onsite training for the first week; thereafter remote. Requires an active, unrestricted RN license from South Carolina.

Responsibilities

• Utilizes available resources to promote quality, cost-effective outcomes.
• Provides active case management: assesses service needs, develops and coordinates action plans with members, monitors services, and implements plans including member goals.
• Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity for requested services and benefit exceptions.
• Reviews and evaluates medical or behavioral eligibility for benefits and clinical criteria by applying clinical expertise, administrative policies, and established clinical criteria to service requests or health management program interventions.
• Assesses, plans, implements, coordinates, monitors, and evaluates medical necessity, options, and services required to support members in managing health, chronic illness, or acute illness.
• Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits.
• Provides telephonic support for members with chronic conditions, high-risk pregnancy, or other at-risk conditions, including intensive assessment/evaluation, risk education, member-centered coaching using motivational interviewing, reflective listening, and readiness-to-change assessment to elicit behavior change and increase program engagement.
• Performs medical or behavioral review/authorization process; ensures coverage for appropriate services within benefit and medical necessity guidelines; uses allocated resources to support review determinations.
• Identifies and makes referrals to appropriate staff (Medical Director, Case Manager, Preventive Services, Subrogation, Quality of Care Referrals, etc.).
• Participates in data collection/input into systems for clinical information flow and proper claims adjudication.
• Demonstrates compliance with applicable legislation and guidelines (e.g., ERISA, NCQA, URAC, DOI, DOL).
• Participates in direct intervention/patient education with members and providers regarding healthcare delivery systems, utilization of networks, and benefit plans.
• May identify, initiate, and participate in on-site reviews; serves as member advocate through continued communication and education.
• Promotes enrollment in care management and health/disease management programs.
• Maintains current knowledge of contracts and network status of service providers and applies appropriately.
• Assists with claims information, discussion, and/or resolution; refers to appropriate internal support areas to ensure proper processing of authorized or unauthorized services.
• Provides appropriate communications (written, telephone) regarding requested services to healthcare providers and members.

Requirements

• Associate degree in Nursing OR graduate of an accredited school of nursing.
• Four years of recent clinical experience in a defined specialty area (e.g., oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopaedic, general medicine/surgery) OR four years in utilization review/case management/clinical (with at least two of those years in clinical practice).
• Active, unrestricted RN license from the United States and in the state of hire OR an active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).

Skills

• Working knowledge of word processing software.
• Knowledge of quality improvement processes and demonstrated ability with these activities.
• Knowledge of contract language and application.
• Ability to work independently, prioritize effectively, and make sound decisions with good judgment.
• Demonstrated customer service, organizational, and presentation skills.
• Demonstrated proficiency in spelling, punctuation, and grammar; strong oral and written communication skills.
• Ability to persuade, negotiate, or influence others; analytical or critical thinking skills.
• Ability to handle confidential or sensitive information with discretion.