Remote Internet Rater Jobs in Lanham, MD (NOW HIRING)

Job Overview:

Pay Range: $46.76hr - $51.76hr

Requirement/Must Have:

• RN license, utilization management, computer skills.
• 5 years Clinical nursing experience.
• 2 years Care Management.
• In lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

Responsibilities:

• Determines medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, Milliman Care Guidelines, Apollo Guidelines, ASAM (American Society of Addiction Medicine), Medicare Guidelines, Federal Employee Program and Policy Guidelines, Medical Policy, and other accepted medical/pharmaceutical references. Follows NCQA Standards, organizational Medical Policy, all guidelines and departmental SOPS to manage their member assignments. Understands all lines of business to include Commercial, FEP, and Medicare primary and secondary policies.
• Conducts research and analysis of pertinent diseases, treatments and emerging technologies, including high cost/high dollar services to support decisions and recommendations made to the medical directors. Collaborates with medical directors, sales and marketing, contracting, provider and member services to determine appropriate benefit application. Applies sound clinical knowledge and judgment throughout the review process. Coordinates non-par provider/facility case rate negotiations between Provider Contracting, providers and facilities. Follows member contracts to assist with benefit determination.
• Makes appropriate referrals and contacts as appropriate. Offers assistance to members and providers for alternative settings for care. Researches and presents educational topics related to cases, disease entities, treatment modalities to interdepartmental audiences.

Nice to Have:

• Working knowledge of managed care and health delivery systems.
• Thorough knowledge of organizational clinical guidelines, medical policies and accreditation and regulatory standards.
• Working knowledge of organizational IT and Medical Management systems, familiarity with web-based software application environment and the ability to confidently use the internet as a resource.

Skills:

• Effective written and interpersonal communication skills to engage with members, healthcare professionals, and internal colleagues.
• Strong assessment skills with the ability to make rapid connection with Member telephonically.
• Ability to work effectively with large amounts of confidential member data and PHI.
• Ability to prioritize workload during heavy workload periods.
• Ability to multitask, prioritize and maintain a dynamic personal organization system that allows for flexibility.
• Proficient in the use of web-based technology and Microsoft Office applications such as Word, Excel and PowerPoint.
• Excellent analytical and problem-solving skills to judge appropriateness of member services and treatments on a case by case basis.

Education and Experience:

• Bachelor's Degree in Nursing.
• RN - Registered Nurse - State Licensure And/or Compact State Licensure Upon Hire Required or LPN - Licensed Practical Nurse - State Licensure.
• CNS-Clinical Nurse Specialist Preferred.

• Medical, Dental, and Vision Insurance
• 401(k) Retirement Plan
• Health Savings Account (HSA)
• Disability Insurance (Short-Term and Long-Term)
• Life and AD&D Insurance
• Paid Sick Leave (where required by applicable state or local law)
• Supplemental Insurance Plans
• Identity Theft Protection
• Pet Insurance
• Employee Wellness Programs
• Employee Assistance Program (EAP)
• Career Growth and Professional Development Opportunities