Remote Utilization Review RN Case Manager Job at A-Line Staffing Solutions in Wo
A-Line Staffing Solutions, Woonsocket, RI, US
Job Description
Job Title: Remote Utilization Review RN Case Manager
Pay: $34.13 an hr | Bi-weekly
Job Type:
- Remote
Shift Options:
M-F 8-5
Remote Utilization Review RN Case Manager Overview:
Reviews documentation and evaluates potential quality of care issues based on clinical policies and benefit determinations.
Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation.
Data gathering requires navigation through multiple system applications.
Staff may be required to contact the providers of record, vendors, or internal Aetna departments to obtain additional information.
Evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines.
Accurately applies review requirements to assure case is reviewed by a practitioner with clinical expertise for the issue at hand.
Commands a comprehensive knowledge of complex delegation arrangements, contracts ,clinical criteria, benefit plan structure, regulatory requirements, company policy and other processes which are required to support the review of the clinical documentation/information.
Pro-actively and consistently applies the regulatory and accreditation standards to assure that activities are reviewed and processed within guidelines.
Condenses complex information into a clear and precise clinical picture while working independently.
Reports audit or clinical findings to appropriate staff or others in order to ensure appropriate outcome and/or follow-up for improvement as indicated.
Remote Utilization Review RN Case Manager Qualifications:
- RN with current unrestricted state licensure or “multi-state privilege” compact nursing license.
- 3+ years of clinical experience
- 2+ years’ experience using personal computer, keyboard navigation, navigating multiple systems and applications; and using MS Office Suite applications (Teams, Outlook, Word, Excel, etc.)
- Compact/Multi-state RN licensure is a plus
- Emergency/critical care experience
- Experience working member grievances/complaints
- Case Management or Utilization Management experience
- Managed care experience
- Medicaid experience
- Behavioral Health experience
- Systems experience: ATV, ASD, GPS, MedCompass, QNXT, and Dynamo
- Experience working with Regulatory Agencies
- Critical thinking skills
- Previous experience working in a remote/virtual environment.
Remote Utilization Review RN Case Manager Benefits:
- Benefits are available to full-time employees after 90 days of employment and include health, optical, dental, life, and short-term disability insurance.
- A 401(k) with a company match is available for full-time employees with 1 year of service on our eligibility dates.
How to Apply:
If you are interested in this position, please apply OR submit your resume to:
Saw Hlaing | shlaing@alinestaffing.com | 412-790-5425