Remote Prior Authorization Rn Jobs in Worcester, MA

Nurse Practitioner Per Diem

This position covers all zip codes in: Worcester County, MA

ComplexCare Solutions (CCS) specializes in helping those in need by delivering high-value home and virtual assessments for health plans nationwide. We pride ourselves on our member engagement aimed towards evaluating current health status, gaps in care, potential health risks and care management opportunities with a focus on driving better clinical outcomes. 

CCS, on behalf of SME Medical Delaware, P.A., is calling on Advanced Practice Providers that are passionate about helping their local communities. We care dearly about those whom we serve, and we need your help to make a difference in the lives of our members. Providers have the opportunity to spend a full hour with these members, which allows them to capture a comprehensive picture of that individual’s personal needs and what is required to keep them in the home and out of the hospital.

Benefit:

This position is eligible to participate in a company 401K plan providing the opportunity to save for retirement through employee contributions. New hires will be automatically enrolled in the company 401(k) plan at a 3% contribution rate with the option to opt out.

• Knowledge of CMS Regulations and NCQA HEDIS Guidelines
• Knowledge of Evidence-based Clinical Practice Standards: American Diabetes Association (ADA), American College of Cardiology (ACC), American Heart Association (AHA), Familiarity with ICD-10 and CPT-4 coding practices
• Complete comprehensive, accurate and thorough review of the assigned member population, including timely completion and submission of all required encounter documentation (paper or electronic)
• Ensure that all pertinent and active medical conditions are documented in the medical record in a manner compliant with CMS/DHHS, Company policy, and client requirements
• Support the physician/patient relationship and ensure timely and adequate communication, documentation of assessment findings, recommendations, need for additional services, emergency services required if necessary and need for follow up and timelines for follow up to primary care provider (PCP) and health plan as required
• Make general recommendations to members intended to improve members' knowledge of their chronic condition(s), such as information concerning recommended testing
• Address and close identified gaps in care (disease-specific or preventive)
• Recognize emergent or urgent situations requiring escalation and take appropriate action as specified in company policies, and as determined by reasonable professional judgment and ethical professional practice standards; and
• Perform, document and communicate results of Point of Care (POC) Testing
• Maintain compliance with Company policies, procedures and mission statement
• Adhere to all confidentiality and HIPAA requirements as outlined within the Company’s Operating Policies and Procedures in all ways and at all times with respect to any aspect of the data handled or services rendered in the undertaking of the position
• Fulfill those responsibilities and/or duties that may be reasonably provided for the purpose of achieving operational and financial success of the Company
• Uphold responsibilities relative to the separation of duties for applicable processes and procedures within your job function
• On a monthly basis, be available for a minimum of 25 slots of availability per month (approximately 37 hours)
• We reserve the right to change this job description from time to time as business needs dictate and will provide notice of such
• Other duties as assigned

• Active un-encumbered license to practice nursing
• ANCC or AANP board certification as a Nurse Practitioner in Family, Adult, Gerontology or Emergency Medicine. 
• Maintains current CPR certification
• Compliance, prior to hire, with recommended Healthcare Personnel Requirements for vaccinations and preventive testing:
• Hepatitis B
• Influenza
• MMR: Measles, Mumps and Rubella
• Pertussis, Tetanus and diphtheria and acellular pertussis (Tdap)
• Varicella
• Tuberculosis
• Home Health exp a plus 
• Must be able to effectively communicate with elderly and chronically ill patients and families
• Understanding of Medicare, Medicaid and Health Plan benefit structures beneficial
• Ability to multitask
• Excellent customer service skills
• Bi-lingual or multi-lingual a plus
• Ability to practice autonomously in a remote clinical environment, including independently conducting patient assessments, formulating evidence-based treatment plans, managing complex chronic conditions, and making sound clinical decisions without direct on-site supervision
• Proficient with computer platforms, electronic health records (EHRs), secure messaging systems, and cloud-based documentation tools

This company utilizes E-Verify.

ComplexCare Solutions (CCS) is proud to be an equal opportunity workplace and is an affirmative action employer. We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender identity or Veteran status. By embracing diversity, equity and inclusion we enhance our work environment and drive business success. ComplexCare Solutions (CCS) strives to reflect the diversity of the communities where we operate and of our clients and everyone whom we serve. We endeavor to create a culture of inclusion in which our associates feel empowered to bring their full, authentic selves to work and pursue their professional goals in an equitable setting. We understand that by fostering this type of culture, and welcoming different perspectives, we generate innovation and growth.