Job Family:
Clinical Appeals Nurse
Travel Required:
Clearance Required:
What You Will Do:
The Remote Utilization Management Nurse - is accountable for performing initial, concurrent, and/or post-service review activities; discharge care coordination; and assisting with efficiency and quality assurance of medical necessity reviews in alignment with federal, state, plan, and accreditation standards. Serves as a liaison between providers/facilities.
Some evening/weekends/holidays required.
General Functions:
Experience and knowledge of clinical guidelines/criteria and the accurate application during a clinical review. Maintains objectivity in decision making by utilizing facts to support decisions.
Supports the care management model as a working partner with providers, facilities, care managers, social workers, pharmacists, and other professional staff.
Able to adhere to communicated utilization management productivity metrics, including call volume and reviews.
Able to adhere to quality standards for utilization management per policy, including appropriate documentation in alignment with guidelines, strict adherence to turn around time, identification of deviations from the progression of care, initiation of a discharge plan, and communication of barriers to other team members.
Demonstrates a solid understanding of managed care trends, payer regulations, reimbursement, and the effect on utilization and outcomes of the different methods of reimbursement.
Demonstrates participation in multi-disciplinary team rounds if designated to cover a facility designed to address utilization/resource and progression of care issues. Assists in developing and implementing an improvement plan to address issues.
Implements a discharge plan to prevent avoidable days or delays in discharge.
Transition individuals to next level of care in coordination with facility Discharge Planner.
Identify and refer complex risk members to care management.
Completes documentation in a timely, complete, and accurate manner in accordance with client benefits, guidelines, and regulatory requirements.
Identify documents and refer cases to the Physician Advisor for medical review when services do not meet medical necessity criteria, the appropriate level of care, and/or potential quality issues.
Utilizes resources efficiently and effectively.
Must be proficient in various word processing, spreadsheet, graphics, and database programs, including Microsoft Word, Excel, PowerPoint, Outlook, etc.
Attention to detail, strong organizational skills and self-motivated.
Ability to independently & accurately make decisions and assimilate multiple data sources or issues related to problem solving.
Ability to work under a timeline/deadline & provide clear & accurate updates to project leader of assignment progress, hours worked & expected outcomes daily.
Familiarity with medical records assembly & clinical terminology, coding terminology additionally beneficial.
Personal responsibility, respect for self and others, innovation through teamwork, dedication to caring and excellence in customer service.
Other duties as assigned.
What You Will Need:
Graduate of an accredited school of nursing, RN.
Current Registered Nurse license.
6+ years of experience including clinical experience, Utilization Management, and Clinical Denials.
Nice To have:
Bachelor’s or master’s degree in Nursing.
Health plan based utilization review.
#Indeedsponsored
The annual salary range for this position is $86,500.00-$129,700.00. Compensation decisions depend on a wide range of factors, including but not limited to skill sets, experience and training, security clearances, licensure and certifications, and other business and organizational needs.
What We Offer:
Guidehouse offers a comprehensive, total rewards package that includes competitive compensation and a flexible benefits package that reflects our commitment to creating a diverse and supportive workplace.
Benefits include:
Medical, Rx, Dental & Vision Insurance
Personal and Family Sick Time & Company Paid Holidays
Position may be eligible for a discretionary variable incentive bonus
Parental Leave
401(k) Retirement Plan
Basic Life & Supplemental Life
Health Savings Account, Dental/Vision & Dependent Care Flexible Spending Accounts
Short-Term & Long-Term Disability
Tuition Reimbursement, Personal Development & Learning Opportunities
Skills Development & Certifications
Employee Referral Program
Corporate Sponsored Events & Community Outreach
Emergency Back-Up Childcare Program
About Guidehouse
Guidehouse is an Equal Employment Opportunity / Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, citizenship status, military status, protected veteran status, religion, creed, physical or mental disability, medical condition, marital status, sex, sexual orientation, gender, gender identity or expression, age, genetic information, or any other basis protected by law, ordinance, or regulation.
Guidehouse will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of applicable law or ordinance including the Fair Chance Ordinance of Los Angeles and San Francisco.
If you have visited our website for information about employment opportunities, or to apply for a position, and you require an accommodation, please contact Guidehouse Recruiting at 1-571-633-1711 or via email at RecruitingAccommodation@guidehouse.com. All information you provide will be kept confidential and will be used only to the extent required to provide needed reasonable accommodation.
Guidehouse does not accept unsolicited resumes through or from search firms or staffing agencies. All unsolicited resumes will be considered the property of Guidehouse and Guidehouse will not be obligated to pay a placement fee.