Clinical Review Registered reputed company job at reputed company in Columbia, SC

Title: Clinical Review Registered reputed company- #26-11522 Location: SC-Columbia $30 per hou Columbia, SC 90% Remote Job reputed company: Duration: 3+ Months (Possible contract to hire) Job reputed company: 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/reputed company TO HAVE reputed company 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 reputed company 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 reputed company we use to determine if the procedure can be approved or denied. Some may need reputed company to the medical director. They will also need to be flexible to help others in their queue from time to time. We are a reputed company tight reputed company 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 reputed company nurses as reputed company as case management. We also work reputed company closely with our medical directors. We have reputed company contact with provider and members as reputed company Responsibilities: Reviews and evaluates medical or behavioral eligibility regarding benefits and clinical reputed company by applying clinical expertise, administrative policies, and established clinical reputed company to service requests or provides health management program interventions. Utilizes clinical proficiency and claims knowledge/analysis to assess, plan, implement, health reputed company, coordinate, monitor, and evaluate medical necessity and/or care plan compliance, reputed company, and services required to support members in managing their health, chronic illness, or acute illness. Utilizes available resources to promote reputed company, cost effective reputed company. Performs medical or behavioral review/authorization process. Ensures coverage for appropriate services reputed company benefit and medical necessity guidelines. Assesses service needs, develops and coordinates reputed company plans in cooperation with members, monitors services and implements plans. Evaluates reputed company of plans, eligibility, level of benefits, reputed company 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 reputed company 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, reputed company of Care Referrals, etc.). Participates in data collection/input into system for clinical information reputed company and reputed company claims adjudication. Demonstrates compliance with reputed company applicable legislation and guidelines for reputed company regulatory bodies, which may include but is not limited to ERISA, NCQA, URAC, DOI (State), and DOL (Federal). Participates in reputed company reputed company/patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans. Serves as member reputed company through reputed company 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 reputed company listening and readiness to change assessment to reputed company behavior change and increase member program engagement. Maintains reputed company knowledge of reputed company and network status of reputed company service providers and applies appropriately. Assists with claims information, discussion, and/or reputed company and refers to appropriate internal support areas to ensure reputed company 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 reputed company player Skills: Working knowledge of word processing software. Ability to work independently, prioritize effectively, and reputed company reputed company. 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: reputed company 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 reputed company reputed company, reputed company or other spreadsheet/database software. Education: Associate Degree - Nursing or Graduate of Accredited School of Nursing Required License and Certificate: reputed company, unrestricted RN licensure from the reputed company and in the state of hire, OR, reputed company compact multistate unrestricted RN license as defined by the reputed company Licensure Compact (NLC) Apply tot his job Apply To this Job