Utilization/Concurrent Review RN (Remote/Telephonic)
Work Schedule: M-F, 8:00 a.m. - 5:00 p.m.
6 month Temp to Perm
Work From Home
**Must live in Orlando or Surrounding Counties**
?Experience completing utilization review
?Familiar with the use of decision making criteria tools (e.g., InterQual, Medical Coverage Guidelines, Medical Necessity, Medicare National Coverage Determination (NCD, Local Coverage Determination (LCD), and Internet only manual for Medicare (IOM)
?Working knowledge working with Current Physician Terminology (CPT) and International Classification of Disease (ICD 9 and ICD 10) coding
?Has a working knowledge of claims components (Post Service)
?Follows and maintains compliance with regulatory requirements (e.g., National Committeee for Quality Assurance (NCQA) and Centers for Medicare and Medicaid Services (CMS)
?Medical Member and Provider Appeals knowledge and experience
?Ensure medical necessity and experimental/investigational claims were processed correctly according to multiple coverage guidelines
?Render medical decisions on claims, identifying questionable medical practices
? Authors within final document to provider appropriate statement supporting final determination
Conducts UM review and discharge planning at the facility level (e.g., Acute, Long Term Acute Care (LTAC), Skilled Nursing Facility (SNF), Acute Inpatient Rehabilitation
The job titles this role typically fill are: Concurrent Review Nurse RN, Pre/Post Service Medical Review RN, Healthcare Appeals Disputes RN, and Healthcare Appeals RN
Candidates may also be asked to train in other clinical roles to support the business.
?Strong computer skills
?2 plus years of utilization management/clinical nursing experience
?Current RN license (must be able to receive a FL RN license within a month of hire)
?Excellent verbal and written communication skills
?Proficient in Microsoft office
Preferred: Bachelors of Science Nursing ( BSN)
We are an equal employment opportunity employer and will consider all qualified candidates without regard to disability or protected veteran status.