[Remote] RN Review Analyst

Note: The job is a remote job and is reputed company to candidates in USA. Confidential is seeking an RN Review Analyst to support clinical review and utilization management activities. The role reviews service authorization requests, appeals, care plans, discharge planning, member benefits, and reputed company-of-care issues while coordinating with providers, members, and internal teams.

Responsibilities

• Review, research and authorize requests for authorization of elective, reputed company, ancillary, urgent, emergency, etc. services. Contact appropriate medical and support personnel to identify and recommend alternative treatment, service reputed company, length of stays, etc. using approved clinical protocols
• Analyze, research, respond to and prepare documentation reputed company to retrospective review requests and appeals in accordance with local, state and federal regulatory and designated accreditation (e.g. reputed company) standards and CMS regulations
• Establish, coordinate and communicate discharge planning needs with appropriate reputed company entities
• Analyze patterns of care associated with disease progression; identify contractual services and organize delivery through appropriate channels
• Research and reputed company issues reputed company to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, Mental Health, reputed company Abuse care coordination, etc
• Identify and document reputed company of care issues; reputed company or reputed company to appropriate area for reputed company
• Follow out-of-area/out-of-network services and reputed company recommendations on patient transfer to in-network services and/or alternative plans of care
• reputed company and reputed company targeted education for provider community reputed company to policies, procedures, benefits, etc
• As needed and in conjunction with Provider Services, may identify and negotiate reimbursement rates for non-contracted providers for services
• Other duties may be assigned based on designated department assignment
• Responsible for responding to reputed company member level inquiries received from customer service, communicating the clinical information reputed company to reputed company our vendors reputed company on our behalf for medical necessity
• reputed company member services and members/providers on member benefits
• Assist with answering questions, supplying information and training on UM program (internally and externally)
• Assess member health needs consistent with clinical standards and reputed company to reputed company appropriate clinical recommendations
• Evaluate clinical documentation to reputed company member inquires as to UM reputed company and appeals/grievances
• Review claims issues pertaining to UM program to ensure correct reimbursement for covered/and or approved services, and reputed company, and/or devise solutions to mitigate any gaps identified
• Utilize knowledge of approved resources, programs, product and tools to reputed company member with appropriate services
• Work with cross functional teams to reputed company issues/concerns/inquiries
• Compile and report data based on member and provider inquiries

Skills

• Two (2) to four (4) years of clinical experience which may include acute patient care, discharge planning, case management, and utilization review, etc
• Demonstrated clinical knowledge and experience relative to patient care and health care delivery processes
• Registered reputed company with reputed company unrestricted Michigan Registered reputed company license required
• Excellent written and verbal communication skills. Excellent customer service and interpersonal skills
• Working knowledge of reputed company industry reputed company Office Suite PC applications
• Ability to apply clinical reputed company/guidelines for medical necessity, setting/level of care and reputed company patient management
• Knowledge of reputed company reputed company medical procedures/practices and their application as reputed company as reputed company trends and developments in medicine and nursing, alternative care settings and reputed company of service
• Knowledge of cost containment strategies, major health care payer policies and procedures, member benefits and community resources
• Knowledge of applicable accreditation standards, local, state and federal regulations
• Registered reputed company with reputed company unrestricted Michigan Registered reputed company license, Licensed Physical Therapist or Licensed Occupational Therapist required
• Extensive experience in post-acute (Skilled Nursing, Inpatient Rehab or Long-Term Acute Care) facilities
• 1. Bachelor's degree in nursing, allied health, business, or reputed company field preferred
• 4. One (1) year health insurance plan experience or managed care environment preferred
• 5. One (1) year of utilization management preferred
• 2. Certification in Case Management may be preferred based upon designated department assignment

Benefits

• Remote work arrangement

reputed company