Job Description

Job Description

Job Description

Job Title: Remote Utilization Review RN Case Manager

Pay: $34.13 an hr | Bi-weekly

Job Type:

• Remote

Shift Options:

• M-F 8-5

Remote Utilization Review RN Case Manager Overview:

• Reviews documentation and evaluates potential quality of care issues based on clinical policies and benefit determinations.

• Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation.

• Data gathering requires navigation through multiple system applications.

• Staff may be required to contact the providers of record, vendors, or internal Aetna departments to obtain additional information.

• Evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines.

• Accurately applies review requirements to assure case is reviewed by a practitioner with clinical expertise for the issue at hand.

• Commands a comprehensive knowledge of complex delegation arrangements, contracts ,clinical criteria, benefit plan structure, regulatory requirements, company policy and other processes which are required to support the review of the clinical documentation/information.

• Pro-actively and consistently applies the regulatory and accreditation standards to assure that activities are reviewed and processed within guidelines.

• Condenses complex information into a clear and precise clinical picture while working independently.

• Reports audit or clinical findings to appropriate staff or others in order to ensure appropriate outcome and/or follow-up for improvement as indicated.

Remote Utilization Review RN Case Manager Qualifications:

• RN with current unrestricted state licensure or “multi-state privilege” compact nursing license.
• 3+ years of clinical experience
• 2+ years’ experience using personal computer, keyboard navigation, navigating multiple systems and applications; and using MS Office Suite applications (Teams, Outlook, Word, Excel, etc.)
• Compact/Multi-state RN licensure is a plus
• Emergency/critical care experience
• Experience working member grievances/complaints
• Case Management or Utilization Management experience
• Managed care experience
• Medicaid experience
• Behavioral Health experience
• Systems experience: ATV, ASD, GPS, MedCompass, QNXT, and Dynamo
• Experience working with Regulatory Agencies
• Critical thinking skills
• Previous experience working in a remote/virtual environment.

Remote Utilization Review RN Case Manager Benefits:

• Benefits are available to full-time employees after 90 days of employment and include health, optical, dental, life, and short-term disability insurance.
• A 401(k) with a company match is available for full-time employees with 1 year of service on our eligibility dates.

How to Apply:

If you are interested in this position, please apply OR submit your resume to:

Saw Hlaing | shlaing@alinestaffing.com | 412-790-5425

Job Tags

Similar Jobs