Job Title: UM Appeals Registered Nurse (RN)

Location: REMOTE, but must reside in NJ, PA, NY, CT and MD

Required: Need to have Active NJ single state or NJ Compact RN License required

Type: 6+ month contract

This Job Will Have The Following Responsibilities

• Assesses patient's clinical need against established guidelines and/or standards to ensure that the level of care and length of stay of the patient are medically appropriate for inpatient stay.
• Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided.
• Coordinates and assists in implementation of plan for members.
• Monitors and coordinates services rendered outside of the network, as well as outside the local area, and negotiate fees for such services as appropriate. Coordinates with patient, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome.
• Coordinates the delivery of high quality, cost-effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care.
• Monitors patient's medical care activities, regardless of the site of service, and outcomes for appropriateness and effectiveness.
• Advocates for the member/family among various sites to coordinate resource utilization and evaluation of services provided.
• Encourages member participation and compliance in the case/disease management program efforts.
• Documents accurately and comprehensively based on the standards of practice and current organization policies.
• Interacts and communicates with multidisciplinary teams either telephonically and/or in person striving for continuity and efficiency as the member is managed along the continuum of care.
• Understands fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes.
• Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes.
• Completes other assigned functions as requested by management.
  
  

Qualifications & Requirements:

• Candidate must reside in NJ, PA, NY, CT and MD
• Active NJ single state or NJ Compact RN License required
• UM Appeals experience
• Minimum of two (2) years clinical experience.
• Proficiency with computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint) and Lotus Notes; prefers knowledge in the use of intranet and internet applications.
• Working knowledge of case/care management principles. Working knowledge of principles of utilization management.
• Prefers basic knowledge of health care contracts and benefit eligibility requirements. Prefers knowledge of hospital structures and payment systems.
  
  

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