Job highlights
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Qualifications
Registered nurses MUST have 4 years or more of RECENT clinical experience
Strong communication skills required to provide telephonic case management to patients and to coordinate with team, providers, and patient representatives regarding patient care
4 years recent clinical in defined specialty area
Or, 4 years utilization review/case management/clinical/or combination; 2 of the 4 years must be clinical
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
Good judgment skills
Demonstrated customer service, organizational, and presentation skills
Demonstrated proficiency in spelling, punctuation, and grammar skills
Demonstrated 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
Required Software and Tools: Microsoft Office
Thorough knowledge/understanding of claims/coding analysis, requirements, and processes
Associate Degree - Nursing, OR, Graduate of Accredited School of Nursing
Responsibilities
Monday through Friday, 8:30 am -5:00 pm
At the end of the week, they will be deployed home with equipment and will work remotely Must be within 2 hours of the Percival rd location Remote after training and must live withing 2 hours of Percival rd office
Will provide equipment
Employee will have to have high-speed internet service that can be plugged directly into the computer
A typical day would like in this role: Employee will be providing telephonic case management for our members
Adaptability for changes in case management processes
Our team works well together to care for our members and support each other
Reviews and evaluates medical or behavioral eligibility regarding benefits and clinical criteria by applying clinical expertise, administrative policies, and established clinical criteria to service requests or provides health management program interventions
Utilizes clinical proficiency, claims knowledge/analysis, and comprehensive knowledge of healthcare continuum to assess, plan, implement, coordinate, monitor, and evaluate medical necessity, options, and services required to support members in managing their health, chronic illness, or acute illness
Utilizes available resources to promote quality, cost effective outcomes
60% Provides active case management, assesses service needs, develops and coordinates action plans in cooperation with members, monitors services and implements plans, to include member goals
Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions
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 thatconsist of: intensive assessment/evaluation of condition, at risk education based on members’ identified needs, provides member-centered coaching utilizing motivational interviewing techniques in combination with reflective listening and readiness to change assessment to elicit behavior change and increase member program engagement
20% Performs medical or behavioral review/authorization process
Ensures coverage for appropriate services within benefit and medical necessity guidelines
Utilizes allocated resources to back up 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 system for clinical information flow and proper claims adjudication
Demonstrates compliance with all applicable legislation and guidelines for all regulatory bodies, which may include but isnot limited to ERISA, NCQA, URAC, DOI (State), and DOL (Federal)
Participates in direct intervention/patient education with members and providers regarding health care delivery system, utilization on 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 programs and/or health and disease management programs
5% Maintains current knowledge of contracts and network status of all service providers and applies appropriately
Assists with claims information, discussion, and/or resolution and refers to appropriate internal support areas to ensure proper processing of authorized or unauthorized services
5% Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members
Specialty areas include: oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, general medicine/surgery
Job description
Duration: 6+ months (Possible Extension)

Job Description:
• Monday through Friday, 8:30 am -5:00 pm. Two late shifts until 8:00 pm per month, 11:30 am - 8:00 pm, no late shifts on Fridays Contract only
• Onsite training at our Percival Road office in Columbia SC for the first week. At the end of the week, they will be deployed home with equipment and will work remotely Must be within 2 hours of the Percival rd location Remote after training and must live withing 2 hours of Percival rd office
• Will provide equipment. Employee will have to have high-speed internet service that can be plugged directly into the computer. Employee must provide their own desk, chair, and a room with a door that closes in which they can work within their home. No persons in the home can be in the room while the employee is working.
• A typical day would like in this role: Employee will be providing telephonic case management for our members.
• Past job instability. Registered nurses MUST have 4 years or more of RECENT clinical experience.
• Strong communication skills required to provide telephonic case management to patients and to coordinate with team, providers, and patient representatives regarding patient care. Adaptability for changes in case management processes. Our team works well together to care for our members and support each other.

Responsibilities:
• Reviews and evaluates medical or behavioral eligibility regarding benefits and clinical criteria by applying clinical expertise, administrative policies, and established clinical criteria to service requests or provides health management program interventions. Utilizes clinical proficiency, claims knowledge/analysis, and comprehensive knowledge of healthcare continuum to assess, plan, implement, coordinate, monitor, and evaluate medical necessity, options, and services required to support members in managing their health, chronic illness, or acute illness. Utilizes available resources to promote quality, cost effective outcomes. 60% Provides active case management, assesses service needs, develops and coordinates action plans in cooperation with members, monitors services and implements plans, to include member goals.
• Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions. 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 thatconsist of: intensive assessment/evaluation of condition, at risk education based on members’ identified needs, provides member-centered coaching utilizing motivational interviewing techniques in combination with reflective listening and readiness to change assessment to elicit behavior change and increase member program engagement. 20% Performs medical or behavioral review/authorization process.
• Ensures coverage for appropriate services within benefit and medical necessity guidelines. Utilizes allocated resources to back up 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 system for clinical information flow and proper claims adjudication. Demonstrates compliance with all applicable legislation and guidelines for all regulatory bodies, which may include but isnot limited to ERISA, NCQA, URAC, DOI (State), and DOL (Federal).
• Participates in direct intervention/patient education with members and providers regarding health care delivery system, utilization on 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 programs and/or health and disease management programs. 5% Maintains current knowledge of contracts and network status of all service providers and applies appropriately. Assists with claims information, discussion, and/or resolution and refers to appropriate internal support areas to ensure proper processing of authorized or unauthorized services. 5% Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members.

Experience:
• 4 years recent clinical in defined specialty area. Specialty areas include: oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, general medicine/surgery. Or, 4 years utilization review/case management/clinical/or combination; 2 of the 4 years must be clinical.

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. Good judgment skills. Demonstrated customer service, organizational, and presentation skills.
• Demonstrated proficiency in spelling, punctuation, and grammar skills. Demonstrated 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.
• Required Software and Tools: Microsoft Office. Preferred Skills and Abilities: Working knowledge of spreadsheet, database software. Thorough knowledge/understanding of claims/coding analysis, requirements, and processes. Preferred Software and Other Tools: Working knowledge of Microsoft Excel, Access, or other spreadsheet/database software.

Education:

Associate Degree - Nursing, OR, Graduate of Accredited School of Nursing

About US Tech Solutions:

US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit www.ustechsolutions.com.

US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, ****** orientation, gender identity, national origin, disability, or status as a protected veteran.

Recruiter Details:

Name: Pragya

Email: [email protected]

Internal Id: 24-23113