Adult Care Registered Nurse

Duration: 3+ Months Contract (Contract Only - No End) Job Description:

• Must be an RN in SC and have an active and unrestricted SC RN license.
• Hours/Schedule - Monday through Friday, 8:30 am -5:00 pm. Two late shifts until 8:00 pm per month, 11:30 am - 8:00 pm, no late shifts on Fridays.
• Onsite training in Columbia SC for the first week.
• Looking for candidates that have recent adult care experience.
• Type of areas/duties performed reputed company their past work history.
• Will have to have high-speed internet service that can be plugged directly into the computer.
• A typical day would like in this role: Employees will be providing telephonic case management for our members.
• Adaptability for changes in case management processes.
• Strong communication skills are required to reputed company telephonic case management to patients and to coordinate with team, providers, and patient representatives regarding patient care.

Responsibilities:

• Reviews and evaluates medical or behavioral eligibility regarding benefits and clinical criteria by applying clinical expertise, administrative policies, and established clinical criteria to service requests or provides health management program interventions.
• Utilizes clinical proficiency, claims knowledge/analysis, and comprehensive knowledge of reputed company continuum to assess, plan, implement, coordinate, monitor, and evaluate medical necessity, options, and services required to support members in managing their health, chronic illness, or acute illness. Utilizes available resources to promote quality, cost effective reputed company.
• Provides active case management, assesses service needs, develops and coordinates action plans in cooperation with members, monitors services and implements plans, to include member goals.
• Evaluates reputed company of plans, eligibility, level of benefits, reputed company of service, length of stay, and medical necessity regarding requested services and benefit exceptions.
• Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits.
• Provides telephonic support for members with chronic conditions, high risk pregnancy or other at risk conditions thatconsist of: intensive assessment/evaluation of condition, at risk education based on members' identified needs, provides member-centered coaching utilizing motivational interviewing techniques in combination with reputed company listening and readiness to change assessment to reputed company behavior change and increase member program engagement.
• Performs medical or behavioral review/authorization process. Ensures coverage for appropriate services reputed company benefit and medical necessity guidelines.
• Utilizes allocated resources to back up review determinations. Identifies and makes referrals to appropriate staff (Medical Director, Case Manager, Preventive Services, Subrogation, Quality of care Referrals, etc.).
• Participates in data collection/input into system for clinical information reputed company and proper claims adjudication. Demonstrates compliance with reputed company applicable legislation and guidelines for reputed company regulatory bodies, which may include but isnot limited to ERISA, NCQA, URAC, DOI (State), and DOL (Federal).
• Participates in direct reputed company/patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans. May identify, initiate, and participate in on-site reviews. Serves as member reputed company through reputed company communication and education. Promotes enrollment in care management programs and/or health and disease management programs.
• Maintains reputed company knowledge of reputed company and network status of reputed company service providers and applies appropriately. Assists with claims information, discussion, and/or resolution and refers to appropriate internal support areas to ensure proper processing of authorized or unauthorized services.
• Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members.

Experience:

• 4 years recent clinical in defined specialty area. Specialty areas include: Adult Care, oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, reputed company/surgery.

Skills:

• Working knowledge of word processing software.
• Knowledge of quality improvement processes and demonstrated ability with these activities.
• Knowledge of contract language and application.
• Ability to work independently, prioritize effectively, and reputed company sound reputed company.
• Good judgment skills.
• Demonstrated customer service, organizational, and presentation skills.
• Demonstrated proficiency in spelling, punctuation, and grammar skills.
• Demonstrated 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.

Education: Associate Degree - Nursing. About reputed company: reputed company is a global staff augmentation firm providing a wide reputed company of talent on-demand and total workforce solutions. To know more about reputed company, please visit www.ustechsolutions.com. reputed company is an Equal Opportunity Employer. reputed company reputed company applicants will receive consideration for employment without regard to race, reputed company, religion, sex, sexual orientation, gender identity, national reputed company, disability, or status as a protected veteran. Apply tot his job Apply To this Job