Title: Clinical Review Registered Nurse- #26-11522 Location: SC-Columbia $30 per hou Columbia, SC 90% Remote Job Description: Duration: 3+ Months (Possible contract to hire) Job Description: Required to be onsite the 1st week of training and then will go remote. Monday-Friday, 8:30am - 5:00pm manager will conduct MS Teams interviews PREFERRED/NICE TO HAVE skill sets/qualities: Must have at least 2 years hospital experience, any other utilization review experience is great, different areas of work is always a plus, must be a team player A typical day would like in this role: Once they are out of training, they have a queue they work the incoming cases out of. They review the requested procedure against the criteria we use to determine if the procedure can be approved or denied. Some may need sent to the medical director. They will also need to be flexible to help others in their queue from time to time. We are a very tight knit group that has been together for a while. We precert outpatient procedures that are done both in office and in the hospital. We work with the concurrent nurses as well as case management. We also work very closely with our medical directors. We have direct contact with provider and members as well 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. Utilizes clinical proficiency and claims knowledge/analysis to assess, plan, implement, health coach, coordinate, monitor, and evaluate medical necessity and/or care plan compliance, options, and services required to support members in managing their health, chronic illness, or acute illness. Utilizes available resources to promote quality, cost effective outcomes. Performs medical or behavioral review/authorization process. Ensures coverage for appropriate services within benefit and medical necessity guidelines. Assesses service needs, develops and coordinates action plans in cooperation with members, monitors services and implements plans. Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions. May initiate/coordinate discharge planning or alternative treatment plans as necessary and appropriate. Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits. 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 data collection/input into system for clinical information flow and proper claims adjudication. Demonstrates compliance with all applicable legislation and guidelines for all regulatory bodies, which may include but is not limited to ERISA, NCQA, URAC, DOI (State), and DOL (Federal). Participates in direct intervention/patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans. Serves as member advocate through continued communication and education. Promotes enrollment in care management programs and/or health and disease management programs. Provides telephonic support for members with chronic conditions, high risk pregnancy or other at risk conditions that consist of: intensive assessment/evaluation of condition, at risk education based on members’ identified needs, provides member-centered coaching utilizing motivational interviewing techniques in combination with reflective listening and readiness to change assessment to elicit behavior change and increase member program engagement. 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: Must have at least 2 years hospital experience, any other utilization review experience is great, different areas of work is always a plus, must be a team player 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. Required Software and Tools: Microsoft Office. Preferred Skills and Abilities: Working knowledge of spreadsheet, database software. Knowledge of contract language and application. Thorough knowledge/understanding of claims/coding analysis/requirements/processes. Preferred Software and Other Tools: Working knowledge of Microsoft Excel, Access or other spreadsheet/database software. Education: Associate Degree - Nursing or Graduate of Accredited School of Nursing Required License and Certificate: Active, unrestricted RN licensure from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC)