Utilization Review RN (Remote - Compact/AZ RN License)
Company: Change Healthcare
Location: Saint Paul
Posted on: May 15, 2022
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Job Description:
Overview of Position
The position is primarily accountable for performing initial
clinical appropriateness review of requests for services that
require prior authorization or retrospective review. The review
process is performed in accordance with established Client (health
plan) protocols/guidelines, benefits, and clinical appropriateness
criteria. This position works closely with the Health Services
Manager and the Medical Director to evaluate, monitor and assure
the appropriateness and medical necessity of selected care for
members as it relates to quality, continuity and cost
effectiveness. This position works with non-clinical staff as part
of the referral and/or authorization process. This position is
responsible for managing utilization and, if necessary, discussing
utilization of service and standards of patient management.
What will be my duties and responsibilities in this job?
+ Performs initial, concurrent, and/or retrospective review of
services that require prior authorization or medical
appropriateness review using health plan benefits, clinical
appropriateness criteria, or plan guidelines/protocols.
+ Documents clinical appropriateness reviews and care management
activities in managed care operating Systems.
+ Facilitates cost effective and quality patient care by effective
communication with physicians, providers and members.
+ Maintains knowledge of regulatory requirements (i.e. URAC), and
state utilization review standards.
+ Ensures authorized services are performed in the most cost
effective appropriate setting.
+ Coordinate discharge planning activities for inpatient level of
care services and facilitate referral to care management
programs.
+ Participates in case review and/or team meetings with managerial
team and Medical Director.
+ Participates in rotational after-hours coverage.
What are the requirements needed for this position?
+ Minimum of 3-5 years of clinical experience
+ One year of care management, utilization management experience,
clinical documentation or clinical auditing experience
+ Successful work history in a clinical setting and/or health
insurance environment
+ Required: Registered Nurse with an active nursing license to
practice in the state of the contracted Client (single state AZ RN
license OR a multi-state/compact RN license)
+ Preferred: Bachelor's Degree in Nursing
What other skills/experience would be helpful to have?
+ Knowledge of medical appropriateness criteria such as InterQual
-, Milliman Care Guidelines -, or eviCore healthcare.
+ Knowledge of CPT, ICD-10, and/or HCPCS codes or coding
experience.
+ Knowledge of precertification and/or medical review processes in
a health care payor or third-party environment.
+ Knowledge of URAC or NCQA standards.
What are the working conditions and physical requirements of this
job?
+ Office/Home Environment.
+ Office Hours: 10am - 6:30pm CST Monday - Friday.
+ After Hours Rotation.
Join our team today where we are creating a better coordinated,
increasingly collaborative, and more efficient healthcare
system!
COVID Vaccination Requirements
We remain committed to doing our part to ensure the health, safety,
and well-being of our team members and our communities. As such, we
require all employees to disclose COVID-19 vaccination status prior
to beginning employment and we may require periodic testing for
certain roles. In addition, some roles require full COVID-19
vaccination as an essential job function. Change Healthcare adheres
to COVID-19 vaccination regulations as well as all client COVID-19
vaccination requirements and will obtain the necessary information
from candidates prior to employment to ensure compliance.
Equal Opportunity/Affirmative Action Statement
Change Healthcare is an equal opportunity employer. All qualified
applicants will receive consideration for employment without regard
to race, color, religion, age, sex, sexual orientation, gender
identity, genetic information, national origin, disability, or
veteran status. To read more about employment discrimination
protections under federal law, read EEO is the Law at
https://www.eeoc.gov/employers/eeo-law-poster and the supplemental
information at
https://www.dol.gov/ofccp/regs/compliance/posters/pdf/OFCCP\_EEO\_Supplement\_Final\_JRF\_QA\_508c.pdf.
If you need a reasonable accommodation to assist with your
application for employment, please contact us by sending an email
to applyaccommodations@changehealthcare.com with "Applicant
requesting reasonable accommodation" as the subject. Resumes or CVs
submitted to this email box will not be accepted.
Click here
https://www.dol.gov/ofccp/pdf/pay-transp\_%20English\_formattedESQA508c.pdf
to view our pay transparency nondiscrimination policy.
California (US) Residents: By submitting an application to Change
Healthcare for consideration of any employment opportunity, you
acknowledge that you have read and understood Change Healthcare's
Privacy Notice to California Job Applicants Regarding the
Collection of Personal Information
(https://www.changehealthcare.com/privacy-notice/privacy-notice-to-california-job-applicants)
.
Change Healthcare maintains a drug free workplace and conducts
pre-employment drug-testing, where applicable, in accordance with
federal, state and local laws.
Change Healthcare is an equal opportunity employer. All qualified
applicant will reveive consideration for employment without regard
to race, color, religion, age, sex, sexual orientation, gender
identity, genetic information, national origin, disability, or
veteran status.
Keywords: Change Healthcare, St. Paul , Utilization Review RN (Remote - Compact/AZ RN License), Other , Saint Paul, Minnesota
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