Job Details
Are you an experienced Registered Nurse - Senior with a desire to excel? If so, then Talent Software Services may have the job for you! Our client is seeking an experienced Registered Nurse - Senior to work at their company in CA that can be worked 100% remotely.
Primary Responsibilities/Accountabilities
- Ensures proper procedure and diagnosis codes are reviewed for submitted procedures/claims.
- Solicits support from SME's, leads, and managers as appropriate
- Triages and prioritizes cases to meet required Turn-around times
- Expedites access to appropriate care for members with urgent needs
- Prepares and submits clinical review cases to Medical Director (MD) for medical director oversight and necessity determination
- Communicate determinations to providers and/or members to in compliance with state, federal, and accreditation requirements
- Develops and reviews member-centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards
- Identifies potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate
- Provides referrals to Case Management, Disease Management, Appeals and Grievance and Quality Departments as necessary
- Assists in the development and implementation of a proactive approach to improve and standardize overall retro claims review for clinical perspectives.
- May require weekend and holiday work and other duties as assigned
Qualifications:
- Nursing- 5 years minimum
- Proficient in Microsoft, outlook, and excel
- RN License required
- Current CA RN
- Requires practical knowledge of job areas typically obtained through advanced education combined with experience.
- Typically, requires a college degree or equivalent experience and 5 years of prior relevant experience.
- Knowledge of CPT-4, ICD-10, HCPCs, and provider billing practices
- Knowledge of Medicare, Medi-Cal, and CMC Regulations and mandates.
- Demonstrate the ability to act independently using sound clinical judgment
Preferred:
- Utilization Management
- Long-term care
- LTSS
- Experienced in working at Skilled Nursing Facility, Long Term Care Custodial Care, and Intermediate Care Facility for Developmental Disability, highly preferred
- Experience in a fast-paced, production and quality environment preferred
- Demonstrated efficient, time management techniques and skills
- Able to handle multiple tasks simultaneously while prioritizing cases to meet regulatory and business-based turnaround time