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Adecco Medical & Science is is looking to hire a Utilization Mgmt Nurse RN to work remotely. MUST RESIDE IN THE STATE OF TEXAS! This position is a four-month contract with the opportunity for a full-time offer. Please read below and apply with an updated resume for consideration:
Essential Responsibilities and Requirements:
Responsible for reviewing proposed hospitalization, home care, and inpatient/outpatient treatment plans for medical necessity and efficiency in accordance with CMS coverage guidelines. The UM Nurse determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination. Generally, work is self-directed and not prescribed. The Utilization Management Nurse works under the direct supervision of an RN or MD.
Essential Job Functions
1. Performs utilization review activities, including pre-certification, concurrent, and retrospective reviews according to guidelines.
2. Determines medical necessity of each request by applying appropriate medical criteria to first level reviews and utilizing approved evidenced based guidelines/criteria.
3. Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services.
4. Answers Utilization Management directed telephone calls, managing them in a professional and competent manner
5. Refers case to a review physician when the treatment request does not meet necessity per guidelines, or when guidelines are not available. Referrals must be made in a timely manner, allowing the review physician time to make appropriate contact with the requesting provider in accordance with departmental policy and within CMS or URAC mandated turnaround times.
6. Reviews, documents, and communicates all utilization review activities and outcomes including, but not limited to, all calls made and received regarding case communication and all demographic and service group information. Sends appropriate system-generated letters to provider and member.
7. May provide guidance and coaching to other utilization review nurses and participate in the orientation of newly hired utilization nurses.
8. Identify and refer all potential quality issues to the Clinical Quality Management Department, and suspected fraud and abuse cases to Compliance Department.
9. Conducts rate negotiation with non-network providers, utilizing appropriate reimbursement methodologies.
10. Documents rate negotiation accurately for proper claims adjudication.
11. Identify and refer potential cases to Disease Management and Case Management.
Performs all other related duties as assigned.
Must have qualifications/experience:
Essential Responsibilities and Requirements:
Responsible for reviewing proposed hospitalization, home care, and inpatient/outpatient treatment plans for medical necessity and efficiency in accordance with CMS coverage guidelines. The UM Nurse determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination. Generally, work is self-directed and not prescribed. The Utilization Management Nurse works under the direct supervision of an RN or MD.
Essential Job Functions
1. Performs utilization review activities, including pre-certification, concurrent, and retrospective reviews according to guidelines.
2. Determines medical necessity of each request by applying appropriate medical criteria to first level reviews and utilizing approved evidenced based guidelines/criteria.
3. Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services.
4. Answers Utilization Management directed telephone calls, managing them in a professional and competent manner
5. Refers case to a review physician when the treatment request does not meet necessity per guidelines, or when guidelines are not available. Referrals must be made in a timely manner, allowing the review physician time to make appropriate contact with the requesting provider in accordance with departmental policy and within CMS or URAC mandated turnaround times.
6. Reviews, documents, and communicates all utilization review activities and outcomes including, but not limited to, all calls made and received regarding case communication and all demographic and service group information. Sends appropriate system-generated letters to provider and member.
7. May provide guidance and coaching to other utilization review nurses and participate in the orientation of newly hired utilization nurses.
8. Identify and refer all potential quality issues to the Clinical Quality Management Department, and suspected fraud and abuse cases to Compliance Department.
9. Conducts rate negotiation with non-network providers, utilizing appropriate reimbursement methodologies.
10. Documents rate negotiation accurately for proper claims adjudication.
11. Identify and refer potential cases to Disease Management and Case Management.
Performs all other related duties as assigned.
Must have qualifications/experience:
- High school diploma or GED equivalent
- RN License Schedule: Full time, Monday - Friday 8am to 5pm
The anticipated wage for this position is between $35.00 and $42.00 Hourly wage may depend upon experience, education, geographic location, and other factors. Weekly pay on Friday!
Benefit offerings include medical, dental, vision, life insurance, short-term disability, additional voluntary benefits, EAP program, commuter benefits and 401K plan. Our program provides employees the flexibility to choose the type of coverage that meets their individual needs. Available paid leave may include Paid Sick Leave, where required by law; any other paid leave required by Federal, State, or local law; and Holiday pay upon meeting eligibility criteria.
Equal Opportunity Employer/Veterans/Disabled
To read our Candidate Privacy Information Statement, which explains how we will use your information, please navigate to https://www.adeccousa.com/candidate-privacy
The Company will consider qualified applicants with arrest and conviction records
