UR/Precert RN

    • Job Tracking ID: 512935-795922
    • Job Location: Remote, USA
    • Job Level: Mid Career (2+ years)
    • Level of Education: 2 year degree
    • Job Type: Full-Time/Regular
    • Date Updated: November 03, 2021
    • Years of Experience: 2 - 5 Years
    • Starting Date: ASAP
    • Salary Type:: Salary
    • Rate:: $60,000+ DOE
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Job Description:

Job Purpose

The Utilization Review/Precertification Registered Nurse utilizes clinical experience and medical guidelines in a collaborative process to assess, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Coordinates medical services requests from providers and determines medical necessity using clinical information provided, criteria guidelines, medical policies, and the specific requirements of the member’s health plan.

Key Functions

  • Conducts telephonic utilization review/precertification services including, prospective, concurrent, and retrospective review utilizing clinical information provided, criteria guidelines, medical policies, and the specific requirements of the member’s health plan. Forwards reviews to the Medical Director as needed.
  • Determines medical necessity and appropriateness of requested inpatient and outpatient services through review of clinical information and application of the appropriate clinical criteria guidelines/medical policies and plan language.
  • Assesses the member's status, future care needs and treatment plan.
  • Ensures timely turn around and accuracy to comply with UM licensing requirements and accreditation standards.
  • Communicates with providers and other departments to facilitate care, transitions of care, and discharge planning.
  • Identifies solutions to non-standard requests and problems.
  • Identifies members for referral opportunities to integrate with other services (i.e., Case Management, Disease Management).
  • Works closely with providers to ensure appropriate utilization of services and effective cost management.
  • Maintains appropriate documentation and records cost management.
  • Attends weekly Leadership Forum/Company View, on-site team meetings and monthly staff meetings.
  • Ensure compliance with security practices and procedures, including HIPAA and HITRUST standards.
  • Protects and enhances the daily culture and environment of AmeriBen. Fosters, supports, and demonstrates the company Core Purpose and Core Values.
  • Performs all duties within the scope of her/his licensure.
  • Performs other duties as assigned or needed.

Experience and Skills:

Minimum Qualifications & Education

  • Current unrestricted R.N. license
  • Minimum of two years of clinical experience.
  • Diverse clinical experience preferred.
  • Proficiency with Microsoft Office products (Word, Excel, Outlook, etc.).
  • Strong verbal and written communication skills.
  • Associates Degree in Nursing (Bachelor’s degree is preferred).
  • Knowledge of medical/health insurance terminology, ICD-10/ICD-11, HIPAA and DOL regulations.
  • Experience using video conferencing.
  • Excellent customer service attitude, accuracy, and professionalism.
  • Ability to efficiently and effectively perform the Key Function Areas with or without a reasonable accommodation without posing a direct safety threat to others or self.

Preferred Qualifications

  • Experience in Utilization Review or Certification in Case Management preferred.
  • Understanding of Case Management functions, self-funded insurance plans and PPO networks.
  • Types 45 wpm, 10-key, and computer knowledge.
  • Strong interpersonal skills and the ability to work effectively with a diverse patient population.
  • Interest in future leadership development opportunities preferred.
  • Effective communication, both verbally and in writing.

AmeriBen is an Equal Opportunity Employer committed to creating an environment of diversity and inclusion for equal employment and advancement opportunities to all employees and applicants for employment. All qualified applicants will receive consideration for employment without regard to race, religion, color, age, national origin, sex, sexual orientation, gender identity and/or expression, genetic information, disability, veteran or military status, or any other category protected by federal, state and/or local law.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. If you are unable to use our online application process due to a disability, please contact the Human Resources Department at humanresources@ameriben.com or call 208-488-7654.