Remote Utilization Review Rn Jobs in Mount Pleasant, SC

Work Arrangement:

This is a remote position with a requirement of a South Carolina resident and a BSN RN license. Minimum of 3 years of professional experience in related field required (i.e., maternal health, labor and delivery, obstetrics, etc.)

Role Overview:

Responsible for managing and coordinating care, services, and social determinants of health for Members with acute, chronic, medically complex, and behavioral health conditions and other health needs. Serves as the primary point of contact for the care team that includes Members, physicians as well as community supports to guide members in achieving their optimal level of health. Utilizes strong assessment and communication skills, critical thinking, and clinical knowledge to identify issues, gaps in care and barriers to care. The Care Manager II develops a plan of care through shared decision making with the Member/caregiver and in collaboration with providers and other care team members to improve the Member's health status, compliance with treatment plans and promote self-management.

Responsibilities:

• Support Members during transitions of care through assessment, coordination of care, education of the discharge plan of care, referrals, and evaluation of the effectiveness of the plan
• Review medication list and educate Members with pharmacy needs, and counsel on side effects and mitigation strategies for specific treatment protocols
• Evaluate, monitor, and update the care plan through regularly scheduled follow-up contacts based on the Member/caregiver progress, needs and preferences
• Establishes points of contact in order to collaborate with identified community, medical, and/or behavioral health teams
• Maintain timely, complete, and accurate documentation of Member interactions in ACFC electronic care management platforms where applicable
• Monitor appropriate utilization and coordinate services with other payer sources, make appropriate referrals, identify and escalate quality of care issues.
• Develop a working knowledge of ACFC electronic care management platforms, care management programs, policies, standard operating procedures, workflows, Member insurance products and benefits, community resources and programs, and applicable regulatory, state, and NCQA requirements
• May identify cases to be presented at care management rounds and follows up with providers on recommendations to achieve optimal outcomes for Members
• Support a positive workplace environment, collaborate, and share clinical knowledge and skills to support our culturally and demographically diverse Member population
• Face-to-face visits may be required at the Member's residence, provider's office, hospitals, behavioral health facilities, and other acute location or community location for education and/or assessment.

Education and Experience:

• Bachelor of Science in Nursing (BSN) is required.
• Minimum of 3 years of professional experience in related field required (i.e., maternal health, labor and delivery, obstetrics, etc.)
• Must engage directly with identified members through face-to-face visits in the community as needed
• At least 3 years of case management experience is preferred
• Proficiency in MS Office (Word, Excel, Outlook, Teams), internet applications, and electronic medical record/documentation systems is essential

Licensure:

• Must hold a current and unrestricted BSN Registered Nurse (RN) license in good standing in South Carolina or a compact state

Our Comprehensive Benefits Package

Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.

For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement.

Your career starts now. We're looking for the next generation of health care leaders.

At AmeriHealth Caritas, we're passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we'd like to hear from you.

Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

Discover more about us at www.amerihealthcaritas.com.