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Job Requirements of Pre-Service Medical Review Nurse - RN:
-
Employment Type:
Contractor
-
Location:
Jacksonville, FL (Onsite)
Do you meet the requirements for this job?
Pre-Service Medical Review Nurse - RN
Careers Integrated Resources Inc
Jacksonville, FL (Onsite)
Contractor
Job Description: Pre-Service Medical Review Nurse - RN
Shift: M-F (8-5) some weekend work, however if a weekend day is worked they can flex on their weekday shifts (no more than 40 hrs./week)
Description:
This position serves as Client's clinical expert in working with providers, facilities and subscribers in overseeing the wellbeing of subscribers while ensuring the proper administration of benefits, cost effectiveness, and the coordination of the delivery of quality care.
Essential functions:
Conduct on-site review of subscriber's medical information in order to ensure appropriate benefit administration.
Consult with providers, facilities' staff, subscribers and their families to ensure cost efficiencies in the delivery of care.
Coordinate with internal and external sources in the on-going management of subscriber's care.
Gather and review subscriber's medical information in order to schedule, based on criticality, on-site reviews. Apply clinical expertise in the completion of subscriber's medical documentation, which become legal documents and part of subscriber's file.
Conduct weekly reviews with internal and external sources on the care and services provided by ClientF to subscribers. Compile weekly, monthly and quarterly reports used to determine cost savings, identify process improvement opportunities and document activities.
Conduct training of new staff members and providers as needed.
Job Requirements:
1-year of utilization management experience
ICD-9 Coding
Excellent planning, organizational skills
Excellent verbal and written communication skills
Self-starter
Ability to work independently
Conflict resolution
Detail oriented
Ability to handle multiple tasks
Decision making skills
Flexibility
Basic PC knowledge
Managed care experience
Understanding of Regulatory Agencies
Experience:
3+ years related work experience or equivalent combination of transferable experience and education
Combined experience in utilization management, case management, home health and clinical
Education:
Nursing - Related Bachelor's degree required
Qualifications/Certificates:
Florida license - Nursing\RN - Registered Nurse - State Licensure And/Or Compact State Licensure
____________________________________________________________________________________________
FLSA: Non Exempt
Contract Only
Equipment Mailed
Preferred:
Ability to work with multiple screens and systems
Managed care experience, Including InterQual, NCD and LCD medical review criteria
Understanding of Regulatory Agencies
Medicare Advantage Experience
Prior FLBL experience
Must:
Previous CMS experience and review of all organization determinations, including pharmacy reviews.
Top candidates are those that have Jiva, Seibel, and Diamond experience.
Remote - Florida
Must have a FL RN License - Unrestricted or Nursing Compact license
Shift: M-F (8-5) some weekend work, however if a weekend day is worked they can flex on their weekday shifts (no more than 40 hrs./week)
Description:
This position serves as Client's clinical expert in working with providers, facilities and subscribers in overseeing the wellbeing of subscribers while ensuring the proper administration of benefits, cost effectiveness, and the coordination of the delivery of quality care.
Essential functions:
Conduct on-site review of subscriber's medical information in order to ensure appropriate benefit administration.
Consult with providers, facilities' staff, subscribers and their families to ensure cost efficiencies in the delivery of care.
Coordinate with internal and external sources in the on-going management of subscriber's care.
Gather and review subscriber's medical information in order to schedule, based on criticality, on-site reviews. Apply clinical expertise in the completion of subscriber's medical documentation, which become legal documents and part of subscriber's file.
Conduct weekly reviews with internal and external sources on the care and services provided by ClientF to subscribers. Compile weekly, monthly and quarterly reports used to determine cost savings, identify process improvement opportunities and document activities.
Conduct training of new staff members and providers as needed.
Job Requirements:
1-year of utilization management experience
ICD-9 Coding
Excellent planning, organizational skills
Excellent verbal and written communication skills
Self-starter
Ability to work independently
Conflict resolution
Detail oriented
Ability to handle multiple tasks
Decision making skills
Flexibility
Basic PC knowledge
Managed care experience
Understanding of Regulatory Agencies
Experience:
3+ years related work experience or equivalent combination of transferable experience and education
Combined experience in utilization management, case management, home health and clinical
Education:
Nursing - Related Bachelor's degree required
Qualifications/Certificates:
Florida license - Nursing\RN - Registered Nurse - State Licensure And/Or Compact State Licensure
____________________________________________________________________________________________
FLSA: Non Exempt
Contract Only
Equipment Mailed
Preferred:
Ability to work with multiple screens and systems
Managed care experience, Including InterQual, NCD and LCD medical review criteria
Understanding of Regulatory Agencies
Medicare Advantage Experience
Prior FLBL experience
Must:
Previous CMS experience and review of all organization determinations, including pharmacy reviews.
Top candidates are those that have Jiva, Seibel, and Diamond experience.
Remote - Florida
Must have a FL RN License - Unrestricted or Nursing Compact license
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