Top 3 Utilization management nurse Jobs in Adrian, Mi

Appeal Analyst RN | Remote | Contract
Walker Healthforce, LLC —United States
- Contract
- Remote
- Nursing
- Microsoft Outlook
- RN License
- Health insurance
- Dental insurance
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Appeal Analyst RN | Remote | Contract

Walker Healthforce, LLC -
United States

Quick Apply

Job Details

Contract

Benefits

Health insurance
Dental insurance
Vision insurance

Qualifications

RN License
Windows
Fax machines
Patient care
Desktop applications
Typing
Faxing
Healthcare software applications
Nurse Licensure Compact (NLC)

Full Job Description

Appeals Nurse | 2 years’ experience | Remote | Contract

Walker Healthforce is seeking a Appeals Nurse with 2 years of experience to support a healthcare client based out of New Jersey. This is a 3-month contract opportunity.

MUST BE A RESIDENT OF THE FOLLOWING STATES: NJ, NY, DE,CT, PA.

START DATE: ASAP
HOURS/SCHEDULE: 8am-5pm EST Monday- Friday
WORKER TYPE: W2

CORE REQUIREMENTS:

Requires an active Compact Licensure - NJ, NY, DE,CT, PA
2 Years of Clinical Experience
Proficiency in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint) and Lotus Notes
3 - 5 years of experience with a background in either Utilization Management, Prior Authorization – Medical Surgical (Inpatient or Outpatient), Complex Case Management w/ exposure to UM, Concurrent or Retrospective Medical Policy Review.
Familiarity interpreting Milliman Care Guidelines MCG guidelines and CareRadius platform exposure is also desirable.
May be required to reach out to providers via phone and fax
Ability to make sound clinical judgements quickly to maintain turnaround time while being accurate.
Strong computer proficiency with general navigation, typing, copy/paste, etc. Relevant tools include: CareRadius, Outlook, Teams, OneNote, Excel
Requires an associate’s or bachelor’s degree (or higher) in nursing and/or a health related field OR accredited diploma nursing school.

ADDITIONAL REQUIREMENTS:

Health Insurance Payer experience preferred, however will accept Health System UM related experience.
Must be located New Jersey, New York, Pennsylvania, Delaware, or Connecticut
Prefers proficiency in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint) and Lotus Notes; prefers knowledge in the use of intranet and internet applications.
Prefers working knowledge of case/care management principles.
Prefers working knowledge of principles of utilization management.
Prefers basic knowledge of health care contracts and benefit eligibility requirements.
Prefers knowledge of hospital structures and payment systems.

WE CONSIDER IT A BONUS IF YOU ALSO HAVE:

Experience with Medicare, Medicaid and/or DSNP programs
Familiarity interpreting Milliman Care Guidelines MCG guidelines, CMS Guidelines and Care Radius platform exposure

JOB RESPONSIBILITIES:

Appeal Analyst RN who will train new hire in the clinical role to complete Utilization Management Appeals and act as an RN II on the team
Assesses patient's clinical need against established guidelines and/or standards to ensure that the level of care and length of stay of the patient are medically appropriate for inpatient stay.
Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided.
Coordinates and assists in implementation of plan for members.
Monitors and coordinates services rendered outside of the network, as well as outside the local area, and negotiate fees for such services as appropriate. Coordinates with patient, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome.
Coordinates the delivery of high quality, cost-effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care.
Monitors patient's medical care activities, regardless of the site of service, and outcomes for appropriateness and effectiveness.
Advocates for the member/family among various sites to coordinate resource utilization and evaluation of services provided.
Encourages member participation and compliance in the case/disease management program efforts.
Documents accurately and comprehensively based on the standards of practice and current organization policies.
Interacts and communicates with multidisciplinary teams either telephonically and/or in person striving for continuity and efficiency as the member is managed along the continuum of care.
Understands fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes.
Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes.
Completes other assigned functions as requested by management.

WHAT WE OFFER:

Competitive compensation package
Weekly pay via Direct Deposit
Medical, Dental & Vision available
401k options

WHY WORK WITH WALKER?

Access to our top ranked team of recruiting and placement specialists
Continuous, one-on-one support from a dedicated engagement manager
Professional resume development and interview preparation

Contact our Recruiting Team today to experience the Walker Healthforce difference!

ABOUT US:
Walker Healthforce is known as the dominant force of performance, precision, expertise, and integrity in the healthcare consulting community! As a certified WMBE, we provide end-to-end healthcare IT and clinical solutions to hospitals, health systems, and payer organizations, including Fortune 100 firms nationwide. We are healthcare experts, we’re custom not commodity and we’ve been exceeding expectations for nearly 20 years. Join forces with us to experience unparalleled results today!

We are an Equal Opportunity Employer committed to a culturally diverse workforce. All qualified applicants will receive consideration for employment without regard to race, religion, color, age, sex, national origin, sexual orientation, gender identity, disability status or protected veteran status.

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utilization management nurse jobs in adrian, mi

Appeal Analyst RN | Remote | Contract

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