This job was posted by https://illinoisjoblink.illinois.gov : For more
information, please see:
https://illinoisjoblink.illinois.gov/jobs/11885928
Job Title: Utilization Review Registered Nurse\
Location: Fully remote\
Duration: 5-6 months contract with future possibilities of extension\
Shift Timing: Monday Friday 8 am 5 pm
Job Description:\
Responsible for the review and evaluation of clinical information and
documentation. Reviews documentation and interprets data obtained from
clinical records or systems to apply appropriate clinical criteria and
policies in line with regulatory and accreditation requirements for
member and/or provider issues. Independently coordinates the clinical
resolution with internal/external clinician support as required.
Requires an RN with unrestricted active license.
Responsibilities:\
Reviews documentation and evaluates potential quality of care issues
based on clinical policies and benefit determinations.\
Considers all documented system information as well as any additional
records/data presented to develop a determination or recommendation.\
Data gathering requires navigation through multiple system
applications.\
Staff may be required to contact the providers of record, vendors, or
internal Aetna departments to obtain additional information.\
Evaluates documentation/information to determine compliance with
clinical policy, regulatory and accreditation guidelines.\
Accurately applies review requirements to assure case is reviewed by a
practitioner with clinical expertise for the issue at hand.\
Commands a comprehensive knowledge of complex delegation arrangements,
contracts, clinical criteria, benefit plan structure, regulatory
requirements, company policy and other processes which are required to
support the review of the clinical documentation/information.\
Pro-actively and consistently applies the regulatory and accreditation
standards to assure that activities are reviewed and processed within
guidelines.\
Condenses complex information into a clear and precise clinical picture
while working independently.
Experience:\
3 years of clinical experience required.\
Managed Care required.\
Medicare experience required.\
Prior Authorization required.\
Utilization Review required.
Preferred:\
MEDCOMPASS or Assure care.
Education:\
RN with current unrestricted state licensure
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 www.ustechsolutions.com.
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.