Remote Utilization Review/Prior Authorization RN Case Manager from A-Line Staffing Solutions

Job Title: Remote Utilization Review/Prior Authorization RN Case Manager

Pay: $34 an hr | Bi-weekly

Job Type:

• Remote

Shift Options:

• Monday-Friday, 8am-5pm (ET) with flexibility based on time zone

Remote Utilization Review/Prior Authorization RN Case Manager Overview:

• This position is responsible for the review and evaluation of protected clinical information and documentation.
  The PQOC team reviews documentation and interprets data obtained from clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider issues.
  ∙ Works Potential Quality of Care cases (Medical), along with Patient Safety Events for Medicare. Independently coordinates the clinical resolution with internal/external clinician support as required.
  ∙ Reviews documentation and evaluates Potential Quality of Care issues based on clinical policies and benefit determinations.
  ∙ Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation.
  ∙ Data gathering requires navigation through multiple system applications.
  ∙ Staff may be required to contact the providers of record, vendors, or internal Aetna departments to obtain additional information.
  ∙ Evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines.
  ∙ Accurately applies critical thinking skills in addition with team based decision rubric to assure case is reviewed by a practitioner with clinical expertise for the issue at hand.
  ∙ This position commands a comprehensive knowledge of clinical criteria, benefit plan structure, regulatory requirements, company policy and other processes which are required to support the review of the clinical documentation/information.
  ∙ Condenses complex information into a clear and precise clinical picture while working independently.
  ∙ Reports clinical findings to appropriate staff or others in order to ensure appropriate outcome and/or follow-up for improvement as indicated.
  ∙ The incumbent must demonstrate strong clinical judgement.

Remote Utilization Review/Prior Authorization RN Case Manager Qualifications:

• Required Qualifications
  ∙ RN with current unrestricted compact license and willing to obtain additional licensure as needed.
  ∙ 3+ years clinical bedside nursing experience in an acute care facility to preferably include experience in any of the following areas: Med/Surg, Critical Care (ICU, PICU/NICU), ER
  ∙ 2+ years’ experience using personal computer, keyboard navigation, navigating multiple systems and applications; and using MS Office Suite applications (Teams, Outlook, Word, Excel, etc.)
  
  Preferred Qualifications
  ∙ Experience working Grievance cases
  ∙ Case Management or Utilization Management experience
  ∙ Managed care experience
  ∙ Systems experience: ATV, GPS, MedCompass, QNXT, Dynamo, MedHok
  ∙ Critical thinking skills
  ∙ Previous experience working in a remote/virtual environment
  ∙ Preference for those in EST or CST zones.

Remote Utilization Review/Prior Authorization RN Case Manager Benefits:

• Benefits are available to full-time employees after 90 days of employment and include health, optical, dental, life, and short-term disability insurance.
• A 401(k) with a company match is available for full-time employees with 1 year of service on our eligibility dates.

How to Apply:

If you are interested in this position, please apply OR submit your resume to:

Saw Hlaing | shlaing@alinestaffing.com | 412-790-5425