Nurse Case Manager

in Healthcare Contract

Job Detail

  • Experience Level Mid Level
  • Degree Type Bachelor of Science in Nursing (BSN)
  • Employment Consulting
  • Working Type Remote
  • Job Reference 0000009602
  • Salary Type Hourly
  • Industry Healthcare
  • Selling Points

    Fully remote role
    Will work 1 weekend day (saturday or sunday)
    No OT – will have 1 day off during the week to total 40 hours
    8 or 10 hour shift available
    During Traing M-F 8-5
    Hours are Eastern Time hours

Job Description

Clinical Evaluation and Review

•   Receive assigned cases for varied member services (i.e. inpatient, outpatient, DME)

•   Review and evaluate cases for medical necessity against medical policy, benefits and/or care guidelines and regulations.

•   Complete work in accordance with timeliness, production, clinical quality/accuracy and compliance standards

•   Provide notifications to member and/or provider, according to regulatory requirements.

•   Assess appropriateness for secondary case review by the Medical Director (MD) for denials and coordinate as needed.

•   May coordinate peer-to-peer review upon provider request when members’ health conditions do not meet guidelines

Collaboration and Documentation

•   Communicate and collaborate effectively with internal and external clinical/non-clinical staff (including MDs) to coordinate work

•   Appropriately and fully document outcome of reviews and demonstrate the ability to interpret and analyze clinical information

•   Utilize detailed clinical knowledge to summarize clinical review against the criteria/guidelines to provide necessary information for MDs.

 

Hiring Requirements

•   RN with 3 years of clinical experience or LPN with 5 years of clinical experience.

•   For Behavioral Health specific roles, other applicable licensure may be considered with a minimum of 3 years of clinical experience.

•   Must have and maintain a valid and applicable clinical license (NC or compact multi-state licensure) to perform described job duties.

  

  • ShareAustin:

Related Jobs