Utilization Review Nurse Job at US Tech Solutions, Providence, RI

Y1d6UzlybjFwdUJ4SmIyZmJBNkVScCtZMUE9PQ==
  • US Tech Solutions
  • Providence, RI

Job Description

Job Description:

  • Participates in the development and ongoing implementation of QM Work Plan activities.
  • Improve quality products and services, by using measurement and analysis to process, evaluate and make recommendations to meet QM objectives
Responsibilities:
  • 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.
  • Responsible for the review and evaluation of clinical information and documentation.
  • Reviews documentation and interprets data obtained form 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 across all lines of business (Commercial and Medicare).
  • Independently coordinates the clinical resolution with internal/external clinician support as required.
  • Processes and evaluates complex data and information sets -Converts the results of data analysis into meaningful business information and reaches conclusions about the data
  • Prepares and completes QM documents based on interpretation and application of business requirements
  • Documents QM activities to demonstrate compliance with business, regulatory, and accreditation requirements
  • Assists in the development and implementation of QM projects and activities
  • Accountable for completing and implementation of QM Work Plan Activities
Experience:
  • 3+ years of experience as an RN
  • 1+ years of inpatient hospital experience
  • Registered Nurse in state of residence
  • Must have prior authorization utilization experience
  • Able to work in multiple IT platforms/systems
Skills:
  • MUST HAVE MEDCOMPASS or ASSURECARE exp.
  • MUST HAVE MANAGED CARE exp and Medicare/Medicaid knowledge.
  • MUST HAVE UM experience, inpatient utilization management review.
  • MUST HAVE 1 YEAR OF UTILIZATION MANAGEMENT EXP, pref. knowledge of Milliman/MCG.
  • MUST HAVE 6 months of Prior Authorization.
Education: • Active and unrestricted RN licensure in state of residence 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 US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran. US Tech Solutions

Job Tags

Similar Jobs

Globe Life AO - Joseph Nelson

~WORK FROM HOME SALES REPRESENTATIVE - Entry Level / Flexible Job at Globe Life AO - Joseph Nelson

 ...? Join Globe Life AO, a mission-driven company thats helping working-class families across the U.S. protect what matters most. We...  ...performers earn $80K$120K+ in year one ~&##127969; Work from home 100% remote with a flexible schedule ~&##128200; Career... 

Mackenzie Hughes LLP

Trusts & Estates Attorney Job at Mackenzie Hughes LLP

 ...legal community since 1884, has an opening for a trusts and estates attorney.Throughout our history we have stayed true to our founders'...  ...should have law firm experience in the following areas: estate planning; estate and trust administration, including proficiency in drafting... 

Air Evac Lifeteam

Helicopter Pilot: 2,000 Flight Hours Required Job at Air Evac Lifeteam

 ...Job Description Job Description: We invite you to join a team of highly skilled emergency medical experts, pilots and mechanics! Our mission of providing care to the world at a moment's notice is at the heart of everything we do. We are caregivers, first and... 

FoundersCard

Principal Product Designer Job at FoundersCard

 ...business benefits, and a curated network of like-minded leadersall designed to accelerate their success. Were entering an exciting...  ..., and design is at the heart of it. As our Principal Product Designer , you will help reimagine the FoundersCard digital experience... 

Collier Simon

Freelance Copywriter Job at Collier Simon

 ...Description Collier.Simon is an independent, full-service creative agency based in Hollywood. We work with our client partners to develop...  ..., and naming. At least 2 years of experience with an ad agency or in house working with a brand marketing team would be preferred...