Medical Review & Appeals RN

Glen Allen, VA 23060

Posted: 03/13/2019 Job Number: 25869

A-Line Staffing is hiring 2 Registered Nurse' s with experience in Utilization Review for current openings in Glen Allen, VA.  Ideal candidate will have 2 years of experience working in Utilization Management.  For more information, contact Aaron Smith at 877-782-3334 x 234.

Job Title: RN Utilization Review
Location: Glen Allen, VA
Max Pay Rate: $70, 000
Benefits: Medical, Dental, Vision available after 30 days employment

SUMMARY:   

Perform prospective, concurrent 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 outreach assessments.

RESPONSIBILITIES/TASKS:
  • 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 related 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 related 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 route to appropriate area for resolution.
  • Follow out-of-area/out-of-network services and make recommendations on patient transfer to in-network services and/or alternative plans of care.
  • Develop and deliver targeted education for provider community related to policies, procedures, benefits, etc.

EMPLOYMENT QUALIFICATIONS:
  • Registered Nurse with current unrestricted Virginia Registered Nurse license required.
  • Bachelor’ s degree in nursing, allied health, business, or related field preferred.
  • 1-2 years of experience working with Utilization Review / Utilization Management and reviewing Medical Files for Cost Effective Care and  Medical Necessity
  • 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.
  • Excellent written and verbal communication skills.  Excellent customer service and interpersonal skills.
  • Working knowledge of current industry Microsoft Office Suite PC applications.

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