Preservice Review Nurse - Remote

The Preservice Review RN is responsible for reviewing requests received from providers, using approved protocols and criteria. (Milliman Care Guidelines or Healthcare Operations Protocols). The RN is expected to approve those requests that meet medical necessity, along with benefit level, and the contractual status of the provider / facility as appropriate for self-funded lines of business. This position is also a resource to new staff and may precept as well.

*** Candidates must be available to work Monday - Friday from 8:00 am - 5:00 pm PST. ***

You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities

• Evaluate and assess each request verifying eligibility and specific product
• Determine benefit level based on site of service
• Utilize written criteria to approve, pend or send the case to the medical director for review
• Send cases for pending process when appropriate
• Maintain at least 98% accuracy of clinical review case notes in Facets
• Maintain productivity standards and maintain compliance with all regulatory agencies including NCQA, DOL, DOI for each state, Medicaid, CMS and OPM
• Maintain at least 98% accuracy in summarizing cases for the Medical Director to review using appropriate protocols based members clinical and benefit information
• Maintain compliance with turnaround times based on the member's product, the type of request and the specific regulatory agency
• Be knowledgeable of and comply with the Nurse Practice Act for each state that licensure is required to perform SHL business
• Precepts / act as a resource for new staff

Required Qualifications

• A current, unrestricted RN license for the state of Nevada
• 2+ years of recent critical care, ER and/or med-surg nursing experience
• Proficient with Microsoft Word to create, edit, save and send documents
• Ability to navigate a Windows environment, Microsoft Outlook, and conduct Internet searches

Preferred Qualifications

• 2+ years Utilization Management experience in managed care, acute or rehab setting
• Knowledge of utilization review process and prior authorization process in a managed health care industry
• Knowledge of ICD9 / CPT coding and Milliman Care Guidelines

Soft Skills

• Detail oriented, excellent organizational skills
• Ability to work well under pressure with sound decision making ability
• Excellent written and oral communication skills

The hourly pay for this role will range from $29 - $52 per hour based on full-time employment.