Registered Nurse Position
Must be an RN in SC and have an active and unrestricted SC RN license. Hours/Schedule - M-F 8:30am 5pm. Onsite training for the first week. Remote once training is complete. A typical day would like in this role: We would sign on the computer at 8:30am and checkthe workload and begin prioritizing the day. The faxes come in electronically and we get requests via phone as well. We would check for date of service or due date to determine the priority of our cases. Then we review the requests against the policy and the member's contract. When reviewing the clinical we determine if it can be reviewed at our level. If not, then it would be sent for review with our medical director. We would then complete the approval or denial and notify the provider. Computer and typing skills are a must as we use several different programs and work remotely. Detail Oriented, Good Communication Skills, Time Management, Organization, Team Oriented, but able to work independently.
Responsibilities:
- Reviews and evaluates medical or behavioral eligibility regarding benefits and clinical criteria by applying clinical expertise, administrative policies, and established clinical criteria to service requests or provides health management program interventions.
- Performs medical or behavioral review/authorization process. Ensures coverage for appropriate services within benefit and medical necessity guidelines.
- Utilizes allocated resources to back up review determinations. Identifies and makes referrals to appropriate staff (Medical Director, Case Manager, Preventive Services, Subrogation, Quality of Care Referrals, etc.).
- Participates in direct intervention/patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans.
- Maintains current knowledge of contracts and network status of all service providers and applies appropriately. Assists with claims information, discussion, and/or resolution and refers to appropriate internal support areas to ensure proper processing of authorized or unauthorized services.
- Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members.
Experience: 2 years clinical experience.
Skills:
- Working knowledge of word processing software.
- Ability to work independently, prioritize effectively, and make sound decisions.
- Good judgment skills.
- Demonstrated customer service, organizational, and presentation skills.
- Demonstrated proficiency in spelling, punctuation, and grammar skills.
- Demonstrated oral and written communication skills.
- Ability to persuade, negotiate, or influence others.
- Analytical or critical thinking skills.
- Ability to handle confidential or sensitive information with discretion.
Education: Associate Degree - Nursing.
About US Tech Solutions: US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit www.ustechsolutions.com. US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.