Registered Nurse, Utilization Management Job at Baptist Health (Florida) (Jacksonville)

Case Manager, Registered Nurse

Remote case manager position working intensely as a telephonic case manager with...

Location

United States , Remote

Salary:

54095.00 - 155538.00 USD / Year

CVS Health

Expiration Date

Until further notice

Requirements

5+ years’ experience as a Registered Nurse
1+ year of experience in a hospital setting
Active, unrestricted RN license in state of residence
Willingness to receive multi-state/compact privileges
1+ years' experience documenting electronically using a keyboard
1+ years' current or previous experience in Oncology, Transplant, Specialty Pharmacy, Pediatrics, Medical/Surgical, Behavioral Health/Substance Abuse or Maternity/Obstetrics experience

Job Responsibility

Work as a telephonic case manager with patients and their care team
Application and/or interpretation of applicable criteria and clinical guidelines
Assess benefits and/or member's needs to ensure appropriate administration of benefits
Incorporate strategies designed to reduce risk factors and barriers
Address complex health and social indicators which impact care planning
Consult with supervisor and others in overcoming barriers
Utilize case management processes in compliance with regulatory requirements
Utilize motivational interviewing skills for member engagement
Identify and escalate member's needs appropriately
Actively reach out to members to collaborate/guide their care

What we offer

Affordable medical plan options
401(k) plan with matching company contributions
Employee stock purchase plan
Wellness screenings
Tobacco cessation programs
Weight management programs
Confidential counseling
Financial coaching
Paid time off
Flexible work schedules

Fulltime

Utilization Management RN

As a Utilization Management RN, you will be crucial in ensuring accurate and com...

Location

United States , Bakersfield

Salary:

47.41 - 70.52 USD / Hour

American Nursing Care

Expiration Date

Until further notice

Requirements

Minimum of 3 years’ recent clinical experience
Graduate of an accredited RN Program
Clear and current CA Registered Nurse (RN) license
Knowledge of nursing theory and ability to apply or modify as appropriate
Knowledge of ICD-10, CPT, HCPCS coding, medical terminology and insurance benefits
Knowledge of legal and ethical considerations related to patient information, PHI and HIPAA regulations

Job Responsibility

Authorization Review: Proactively, concurrently, or retroactively reviewing referral authorization requests, gathering necessary information, and escalating to the Medical Director when needed
Compliance & Accuracy: Meeting turnaround times and accuracy standards
Provider Network: Ensuring authorized services are with contracted providers and coordinating with contracting for new agreements
Care Coordination: Identifying cases for additional case management and collaborating with internal departments to coordinate patient care
Quality & Cost-Effectiveness: Adhering strictly to utilization management policies to promote quality, cost-effective care
Denial Notice Composition: Drafting compliant, clear, and member-specific denial letters in accordance with federal, state, and health plan regulations, as well as NCQA standards

What we offer

medical, prescription drug, dental, vision plans, life insurance, paid time off, tuition reimbursement, retirement plan benefit(s) including, but not limited to, 401(k), 403(b), and other defined benefits offerings, Health Spending Account (HSA), Long Term Disability, 401k retirement plan with a generous employer-match, Sick Leave

Fulltime

Medical Appeals/Grievance Specialist II - Registered Nurse

Responsible for utilizing clinical acumen and managed care expertise related to ...

Location

United States , Phoenix

Salary:

Not provided

Blue Cross Blue Shield of Arizona

Expiration Date

Until further notice

Requirements

1 year experience in clinical and health insurance or other healthcare related field
3 years experience in clinical and health insurance or other healthcare related field AND 1 year Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
5 years experience in clinical and health insurance or other healthcare related field AND 2 years Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
8 years experience in clinical and health insurance or other healthcare related field AND 3 years above satisfactory job performance in the managed care environment with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
Associate’s Degree in a healthcare field of study or Nursing Diploma
Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) or a compact state as a Registered Nurse (RN), a Physical Therapist (PT) or a Licensed Master Social Worker LMSW.
Intermediate PC proficiency
Intermediate skill using office equipment, including copiers, fax machines, scanner and telephones
Maintain confidentiality and privacy
Advanced clinical knowledge

Job Responsibility

Perform in-depth analysis, clinical review and resolution of provider appeals/inquiries, corrected claims and subscriber reconsiderations, member appeals, corrected claims and provider grievances for all lines of business
Identify, research, process, resolve and respond to customer inquiries primarily through written / verbal communication.
Respond to a diverse and high volume of health insurance appeal related correspondence on a daily basis.
Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of appeal, grievance and reconsideration requests.
Maintain complete and accurate records per department policy.
Meet quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines and required by State, Federal and other accrediting organizations.
Demonstrate ability to apply plan policies and procedures effectively.
Consult and coordinate with various internal departments, external plans, providers, businesses, and government agencies to obtain information and ensure resolution of customer inquiries.
Attend staff and interdepartmental meetings.
Participate in continuing education and current developments in the fields of medicine and managed care.

Fulltime

Outpatients Registered Nurse

To ensure that standards of patients care are consistently maintained at all tim...

Location

United Kingdom , Chelmsford

Salary:

Not provided

Phoenix Hospital Group

Expiration Date

Until further notice

Requirements

Registered Nurse with 2+ years post qualification experience
Presently working in a hospital environment – essential
Experience in a private hospital environment – desirable
Experience in mentoring colleagues and HCA’s
Enthusiastic, committed and flexible team player, sensitive to patient needs

Job Responsibility

Assess, implement and evaluate nursing care with an evidence based approach, providing a high standard of clinical and customer care to all patients
Assist with the creation and review of patient centred standards of care
Promote an environment receptive to change
Attend and participate in department meetings
Participate in the mentorship of HCA’s and new starters
Provide a supportive staff environment
Support colleagues and work co-operatively to promote good team morale on the ward
Identify areas for personal and professional development
Support junior staff in their professional development journey
Maintain and expand professional knowledge participating in nursing / hospital educational programs

Fulltime

Wellness Registered Nurse

The Fox Hill Village Health & Wellness Center is a Nurse Led model that provides...

Location

United States , Westwood

Salary:

110000.00 USD / Year

Fox Hill Village

Expiration Date

Until further notice

Requirements

Holistic approach to nursing practice
Strong assessment, triage, and judgement skills
Demonstrated client and family education skills
Strong interpersonal, written, clinical documentation and oral communication abilities
Strong listening skills, while being approachable and articulate
Demonstrated effective collaboration and organizational skills
Exceptional computer skills, with proficiency with Microsoft Office (Windows, Outlook, Excel)
Ability to work weekends, holidays, and be on call for emergencies
Minimum of a Bachelor’s degree in Nursing
Five years of experience as a Registered Nurse, with two or more years’ experience in Gerontology preferred

Job Responsibility

Works collaboratively with Fox Hill Village health professionals to provide optimum nursing services to the residents of Fox Hill Village
Demonstrates the competencies of the gerontological registered nurse as described in the Standards of Gerontological Nursing Practice
Utilizes a holistic approach in providing nursing services to residents
Develops individualized wellness plans and goals with individual residents to maximize health and well-being and help residents attain their highest level of functioning
Uses Evidence-Based Practice methods in providing care to residents
Utilizes comprehensive assessment skills in triage of residents seeking care for health problems, minor illnesses and injuries and in performing wellness assessments
Includes family members when requested by residents or when otherwise appropriate
Implements treatments and other elements of care prescribed by a physician’s order or by the primary care provider
Maintains competency in Point of Care (CLIA-waived) Testing conducted in the Health & Wellness Center
Manages and performs periodic health maintenance/health monitoring activities as requested or needed by residents, such as blood pressure readings, weight measurement, etc

What we offer

401(k)
401(k) matching
Dental insurance
Employee assistance program
Flexible schedule
Flexible spending account
Health insurance
Life insurance
Paid time off
Referral program

Fulltime