Are you ready for a new career path?
Do you want to land a more fulfilling job than the one you're in now?
Are you looking for a company that values integrity, initiative, good judgment and teamwork?
As a part of our continued growth, we are searching for the right individuals to join our team!
We are looking for individuals with a strong desire to embrace and represent our unique culture founded on our Core Values of Integrity, Initiative, Good Judgment and Teamwork and our passion for changing lives through leadership development.
AmeriBen is a leader in the benefits administration industry with a strong track record for consistent double-digit growth (doubling every five years for the past 30 years). We are experiencing wonderful nationwide growth and need effective, dynamic leaders with good values to help us continue this momentum.
There's an energy and excitement here, an opportunity to work with a diverse culture while sharing a goal to improve the lives of others, as well as our own. The result is a culture of performance that's driving the health care industry forward.
If you are an RN with a passion for helping people succeed in managing their health, our position may be for you. The AmeriBen Medical Management team provides utilization management, case and disease management services to thousands of members navigating the complex world of healthcare. You have the chance to change lives with the benefits of a salaried position combined with a work-life balance!
The Utilization Review/Precertification Registered Nurse conducts pre-certification, inpatient, retrospective, and appropriateness of treatment setting reviews by utilizing clinical guidelines and medical policies in compliance with department guidelines and consistent with the member’s plan benefit. Develops relationships with physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members.
Key Result Areas
- Conducts utilization review/precertification services including prospective, concurrent, medical necessity and retrospective reviews.
- Determines medical necessity and appropriateness of requested inpatient and outpatient services through review of clinical information and application of the specific clinical criteria guidelines, medical policies and plan benefit.
- Provides authorization of services, or forwards requests to physician/Medical Advisor for determination.
- May access and consult with peer clinical reviewers, Medical Advisor and/or delegated clinical reviewers to help ensure medically appropriate, quality, cost effective care throughout the medical management process.
- Facilitates communication with health care providers involved with the care of the member to obtain complete and accurate information, to advise of determinations, and to educate regarding medical management processes.
- Facilitates appeal and external review requests in coordination with the Appeals department.
- Communicates with providers and other departments to facilitate care, referrals, transitions of care, and discharge planning.
- Identifies solutions to non-standard requests and problems.
- Maintains concise documentation and confidentiality of records and information.
- Attends on-site weekly company/team meetings and monthly staff meetings.
- Performs all duties within the scope of licensure.
- After six months of demonstrated efficiency in position, working from home may be possible.