What You’ll Be Doing:
Performing precertification, prior approvals, concurrent and retrospective reviews, and coordination of discharge planning. Tasks are performed within the RN scope of practice, under Medical Director direction, using independent nursing judgement and decision-making, physician-developed medical policies, and clinical decision-making criteria sets. Acts as a member advocate by expediting the care process through the continuum, working in concert with the health care delivery team to maintain high quality and cost effective care delivery.
- Assess member’s needs
- Identify solutions to problems and non-standard requests
- Follows and maintains compliance with regulatory agency requirements
- Maintain courteous, professional attitude
- Collaborate with staff, physicians, care/service coordinators, and medical directors to coordinate and provide the level of care necessary to meet member’s health need
- Ability to work remotely
The Experience You’ll Need (Required):
- Licensed Registered Nurse (Multi-State)
- Experience with Milliman (MCG) clinical decision-making criteria sets
- Minimum of one year of recent experience with Utilization Review/Utilization Management activities in a managed care environment in the past year
- Knowledge of managed care principles
EEO Statement:It is RNa Partners policy to provide equal employment opportunity to all employees and applicants for employment without regard to race, sex, sexual orientation, color, creed, religion, national origin, age, disability, marital status, parental status, family medical history or genetic information, political affiliation, military service or any other non-merit based factor in accordance with all applicable laws, directives and regulations of federal, state and city entities.