Preservice Review Nurse RN - Remote

The Integrated Care Team leverages a cross-functional approach, supporting the member end to end, with close collaboration and co-management. Generally, work is self-directed and not prescribed; is able to work with less structured and more complex issues.

The Preservice Review/Prior Authorization RN will manage the full array of health care services, spanning both outpatient and Inpatient settings and with support from some specialized clinical teams, serves as a resource to others. This new cross-functional collaboration provides an opportunity to deliver the next generation clinical model, integrating services from precertification, inpatient concurrent review, post-acute review, discharge planning, medical and behavioral care management and prevention to improve quality of care and patient outcomes. Candidates for this position would be required to support cross-training to multiple roles: Prior Authorization (PA), Post-Acute Care Management (PACM), Inpatient Care Management (ICM) and Discharge Care Management (DCM) to support fluctuating inventory within the Integrated Care Team.

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

Primary Responsibilities

• Perform initial and ongoing reviews pertaining to primary role (PA, ICM, DCM, PACM), appropriately applying clinical criteria (InterQual, policies, National and Local Coverage Determinations) for approval and sending to Medical Directors if review is necessary for determining an adverse determination
• Collaborate with Medical Directors, clinical peers and Health Plan partners on performing appropriate clinical decision making and/or referrals
• Apply clinical expertise when discussing case with internal and external Case Managers and Physicians
• Follow all Standard Operating Procedures in end-to-end management of cases
• Participate in team meetings, education discussions and related activities
• Maintain compliance with Federal, State and accreditation organizations

Required Qualifications

• Current, unrestricted RN license in state of residency
• 3+ years of RN experience
• Proficient computer skills including Microsoft Office Suite (Teams, Word, Excel, and Outlook)
• Demonstrated ability to work independently
• Demonstrated effective verbal and written communication skills
• Willing or ability to work weekends

Preferred Qualifications

• Bachelor of Science degree in Nursing or a Master of Science degree in Nursing
• Compact RN License
• 2+ years of Case Management experience
• Clinical experience in an inpatient/acute setting, long-term care, acute rehabilitation, or skilled nursing facilities
• Experience performing Discharge Planning
• Experience with InterQual
• Utilization Review experience

The hourly pay for this role will range from $29.00 - $52.00 per hour based on full-time employment.