Job Description:
Monday Friday, 8:30am-5pm contract to hire onsite interview panel interviews with up to 3 supervisors/managers. Will be required to be onsite for training and then moved to work remote. Equipment will be provided.
Prefer 2 yrs. UM and/or appeals experience. We want to see all candidates with experience with prior insurance, utilization management, case management, surgical or behavioral health experience.
This role conducts reviews of previously denied services to determine if the medical necessity and contract provisions have been applied correctly or if newly submitted information would change the determination.
Candidate for this position must have broad clinical background, flexibility. This job is mostly solitary work after training. The team works well to share knowledge and background.
Responsibilities:
Researches the substance of complex appeal or retrospective review requests including pre-pay and post-payment review appeal requests. Provides thorough clinical review or benefit analysis to determine if the requested services meet medical necessity guidelines. Documents decisions within mandated timeframes and in compliance with applicable regulations or standards.
Documents the basis of the appeal or retrospective review in an accurate and timely manner and in accordance with applicable regulations or standards. Performs thorough research of the substance of service appeals by both member and provider based on clinical documentation, contractual requirements, governing agencies, policies and procedures, while adhering to confidentiality regulations regarding protected health information.
Performs appeal and retrospective reviews demonstrating ability to define and determine precedence of pertinent issues in application of policies and procedures to clinical information and or application to benefit or policy provisions. Performs special projects including reviews of clinical information to identify quality of care issues.
Experience:
2 years clinical experience plus 1 year utilization/medical review, quality assurance, or home health, OR, 3 years clinical.
Skills:
Required Skills and Abilities: Working knowledge of word processing software. Ability to work independently, prioritize effectively, and make sound decisions. Working knowledge of managed care and various forms of health care delivery systems. Strong clinical experience to include home health, rehabilitation, and/or broad medical surgical experience. Knowledge of specific criteria/protocol sets and the use of the same. Good judgment skills. Demonstrated customer service, organizational, 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: Microsoft Office. Preferred Skills and Abilities: Administrative Law Judge (ALJ) process. Knowledge of statistical principles. Knowledge of National Committee for Quality Assurance (NCAG). Knowledge of Utilization Review Accreditation Commission (URAC). Knowledge of South Carolina Department of Insurance (SCDOI). Knowledge of US DOL and Health Insurance Portability/Accountability Act (HIPAA) standards/regulations. Excellent organizational and time management skills. Knowledge of claims systems. Presentation skills.
Preferred Software and Other Tools: Excel or other spreadsheet software. Ability to effectively use Microsoft Office applications, such as Word, Power point and Excel. Work Environment: Typical office environment. Deadline driven environment.
Education:
Associate Degree - Associate Degree - Nursing, or Graduate of Accredited School of Nursing.
Required License/Certificate: Active, unrestricted RN licensure from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC)
About US Tech Solutions:
US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit .
US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity,
national origin, disability, or status as a protected veteran.
Recruiter Details
Name: Vivek Kumar
Email: Vivek.kumar@ustechsolutionsinc.com
Internal Job ID: 25-30459
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