Lead Clinical Review Nurse - Correspondence

apartment Centene location_onNV, US

Apply Now

$35.49 - $63.79 / HOUR

Apply Now

Location: Position is remote. Prefer candidate to live in PST time zone.

Schedule: Looking for someone who will work Tuesday-Saturday. 8-5 PST.

Position Purpose: Oversees correspondence letters based and supports overall team needs. Reviews outcomes in accordance with National Committee for Quality Assurance (NCQA) standards. Works with senior management to identify and implement opportunities for improvement.

Oversees the clinical review of outcomes including creating and editing correspondence letters with the correspondence team based on determinations in accordance with National Committee for Quality Assurance (NCQA) standards
Manages the audits of correspondence to ensure they are processed in accordance with Federal, State, and NCQA standards
Provides expert insight and guidance on the clinical review process of correspondence to ensure compliance with all applicable State and Federal regulations
Provides subject matter expertise insights to investigate and resolve issues including comprehensive review of clinical documentation, clinical criteria/guidelines, and policy, including insurance rejections due to coding issues and escalates as appropriate to resolve issues in a timely manner
Acts as a point of contact for escalated, advanced issues and/or questions related to correspondence with the state, local, and federal agencies including third party payer and providers to ensure issues are resolved in a timely manner
Oversees clinical quality and process improvement initiatives related to clinical quality indicators and financial metrics
Manages data needed to identify trends and provide recommendations to senior management of process improvements within utilization management
Manages and oversees cases to ensure timely resolution and logs of actions and/or decisions are appropriately documented
Provides training and education to the interdepartmental teams on training needed within the utilization management team based on trends
Partners with leadership to improve processes and procedures to prevent recurrences based on industry best practices
Provides guidance, subject matter expertise and training as needed
Performs other duties as assigned
Complies with all policies and standards

Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 5 – 7 years of related experience.

Expert knowledge of Medicare and Medicaid regulations preferred.

Expert knowledge of utilization management processes preferred.

License/Certification:

LPN - Licensed Practical Nurse - State Licensure required- Compact License

Location: Position is remote. Prefer candidate to live in PST time zone.

Schedule: Looking for someone who will work Tuesday-Saturday. 8-5 PST.

Pay Range: $35.49 - $63.79 per hour

Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

Share this job

Related Jobs

Utilization Review

Full-time

Clinical Review Nurse - Concurrent Review

apartment Centene location_onNV

$26.50 - $47.59 / HOUR

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. This is a Remote position - Nevada LPN or RN License required Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member. Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collaborates with care management on referral of members as appropriate Performs other duties as assigned Complies with all policies and standards Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. 2+ years of acute care experience required. Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: RN - NV State Licensure preferred Pay Range: $26.50 - $47.59 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

Utilization Review

Full-time

Clinical Claims Review RN - Remote

apartment UnitedHealthcare location_onLas Vegas, NV

$28.27 - $50.48 / HOUR

At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and optimized. Ready to make a difference? Join us to start Caring. Connecting. Growing together. Under direct supervision of the Manager and Supervisors, Clinical Claims Review, conducts retrospective reviews for appropriateness of diagnostic procedures, inpatient, ambulatory, emergency room, and evaluation & management services, coding levels, etc., utilizing standardized criteria, protocols, and guidelines. This RN will train and provide coverage for the Medical Adjudication and Coding Units in Clinical Claims Review. If you reside within a commutable distance from the Las Vegas, NV area, you will have the flexibility to work remotely* as you take on some tough challenges. Primary Responsibilities Provide support to all units within Claims to ensure all clinical components are met for CMS, NCQA, URAC, DOL, DOI, and all other State and Federal entities Identify business priorities and necessary processes to triage and deliver work Use appropriate business metrics (e.g. case turnaround time, productivity) and applicable processes/tools to optimize decisions and clinical outcomes Review assigned claims (e.g. ER, inpatient, diagnostic procedures) to evaluate medical necessity and determine appropriate levels of care and site of service Maintain incoming pended claims, electronic inquiries and medical records work queue Identify information missing from clinical documentation; request additional clinical documentation as appropriate Make determinations per relevant protocols (e.g., deny, return to claims system, designate as inappropriate referral, proceed with clinical or non-clinical research) Prepare claims for medical director review by completing summary and attaching all pertinent medical information. Interpret codes and determine coding accuracy Use available resources to further interpret coding accuracy Identify relevant information needed to make clinical determination Review other approved sources of clinical information and use data for making clinical determinations (e.g., previous diagnoses, authorizations/denials) Participate in various special projects as assigned Attend assigned meetings relating to clinical reviews and other aspects of job function Perform all job functions with a high degree of discretion and confidentiality in compliance with federal, company & departmental confidentiality guidelines Candidate must be available to complete 3-6 week onsite training. *** You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications Current, unrestricted RN license for the state of Nevada 2+ years of nursing experience in clinical claims review or utilization review 1+ years of acute clinical nursing experience Proficiency with Microsoft Word, Excel and Outlook Preferred Qualifications Bachelor's degree CPC certification Knowledge of managed care delivery system concepts such as HMO/PPO Knowledge of evidenced based and standardized criteria such as InterQual Knowledge of CPT, and ICD-10 coding Broad knowledge of medical conditions, procedures and management Demonstrated ability to learn and differentiate between company products and the benefits All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $28.27 to $50.48 per hour based on full-time employment. We comply with all minimum wage laws as applicable. At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission. UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.

Utilization Review

Full-time

Clinical Claims Reviews RN - Remote

apartment UnitedHealthcare location_onLas Vegas, NV

$28.27 - $50.48 / HOUR

At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together. Under direct supervision of the Manager and Supervisors, Clinical Claims Review, conducts retrospective reviews for appropriateness of diagnostic procedures, inpatient, ambulatory, emergency room, and evaluation & management services, coding levels, etc., utilizing standardized criteria, protocols, and guidelines. This RN will train and provide coverage for the Medical Adjudication and Coding Units in Clinical Claims Review. If you reside within the state of Nevada, you will have the flexibility to work remotely* as you take on some tough challenges. Primary Responsibilities Provide support to all units within Claims to ensure all clinical components are met for CMS, NCQA, URAC, DOL, DOI, and all other State and Federal entities Identify business priorities and necessary processes to triage and deliver work Use appropriate business metrics (e.g. case turnaround time, productivity) and applicable processes/tools to optimize decisions and clinical outcomes Review assigned claims (e.g. ER, inpatient, diagnostic procedures) to evaluate medical necessity and determine appropriate levels of care and site of service Maintain incoming pended claims, electronic inquiries and medical records work queue Identify information missing from clinical documentation; request additional clinical documentation as appropriate Make determinations per relevant protocols (e.g., deny, return to claims system, designate as inappropriate referral, proceed with clinical or non-clinical research) Prepare claims for medical director review by completing summary and attaching all pertinent medical information Interpret codes and determine coding accuracy Use available resources to further interpret coding accuracy Identify relevant information needed to make clinical determination Review other approved sources of clinical information and use data for making clinical determinations (e.g., previous diagnoses, authorizations/denials) Participate in various special projects as assigned Attend assigned meetings relating to clinical reviews and other aspects of job function Perform all job functions with a high degree of discretion and confidentiality in compliance with federal, company & departmental confidentiality guidelines Candidate must be available to complete 3-6 week onsite training. *** You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications Current, unrestricted RN license for the state of Nevada 2+ years of nursing experience in utilization review, case management, clinical claims review, or similar field with 1+ years of experience working in a hospital or clinical setting Proficiency with Microsoft Word, Excel and Outlook Preferred Qualifications Bachelor's degree CPC certification Knowledge of managed care delivery system concepts such as HMO/PPO Knowledge of evidenced based and standardized criteria such as InterQual Knowledge of CPT, and ICD-10 coding Broad knowledge of medical conditions, procedures and management Proven ability to learn and differentiate between company products and the benefits All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $28.27 to $50.48 per hour based on full-time employment. We comply with all minimum wage laws as applicable. At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission. UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

Utilization Review

Full-time

Care Review Clinician RN (BH Licensed) Nevada

apartment Molina Healthcare location_onNV

**Nevada residents preferred. Candidates who do not live in Nevada must be willing to work Pacific Business Hours . JOB DESCRIPTION Job Summary Provides support for member clinical service review processes specific to behavioral health. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations, and ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Assesses services for members - ensuring optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. • Analyzes clinical service requests from members or providers against evidence based clinical guidelines. • Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. • Conducts reviews to determine prior authorization / financial responsibility for Molina and its members. • Processes requests within required timelines. • Refers appropriate cases to medical directors and presents cases in a consistent and efficient manner. • Requests additional information from members or providers as needed. • Makes appropriate referrals to other clinical programs. • Collaborates with multidisciplinary teams to promote Molina care model. • Adheres to utilization management (UM) policies and procedures. • May work collaboratively with appropriate departments to provide applied behavior analysis (ABA)/behavioral health therapy (BHT) services to Molina members with autism spectrum disorder (ASD) and other related disorders. • May approve requests for BHT by reviewing behavioral assessments and treatment plans for medical necessity and BHT best practice guidelines. This includes but is not limited to: psychological evaluation requests, comprehensive diagnostic evaluations, functional behavioral assessments, and progress reports. • May perform ongoing monitoring of BHT treatment plans to evaluate effectiveness and treatment efficacy. • May provide peer to peer consultation BHT in-network providers to support treatment planning and maximize member progress. • May work collaboratively with ABA providers to ensure best service practices for members. • May create and develops forms, recommendations and guidelines and training for BHT service delivery. • May collaborate and coordinate with behavioral health medical directors, and senior medical directors to ensure proper management of the BHT benefit. Required Qualifications • At least 2 years health care experience, including experience in behavioral health and/or hospital acute care, or equivalent combination of relevant education and experience. • Licensed Clinical Social Worker (LCSW), Licensed Professional Counselor (LPC), Licensed Professional Clinical Counselor (LPCC), Licensed Marriage and Family Therapist (LMFT) or equivalent behavioral health licensure. License must be active and unrestricted in state of practice. • May require behavioral analyst experience, and/or board certification/licensure as a behavioral analyst (BCBA and/or LBA). • Demonstrated knowledge of community resources. • Ability to operate proactively and demonstrate detail-oriented work. • Ability to work within a variety of settings and adjust style as needed - working with diverse populations, various personalities and personal situations. • Ability to work independently, with minimal supervision and demonstrate self-motivation. • Responsive in all forms of communication, and ability to remain calm in high-pressure situations. • Ability to develop and maintain professional relationships. • Excellent time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change. • Excellent problem-solving, and critical-thinking skills. • Strong verbal and written communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications Certified Professional in Healthcare Management (CPHM). Recent hospital experience in an intensive care unit (ICU) or emergency room. ASAM Certification for behavioral health Previous experience with MCG guidelines. At least 2 years of experience with inpatient concurrent review, prior authorization and managed care; Acute care hospital experience with discharge planning and critical thinking skill set. Knowledge with Nevada Medicaid State rules and regulations (Medicaid Service Manual, billing guidelines, Provider Types, fee schedules) Ability to handle change in fast paced environment Team player with positive attitude for success Preferred License, Certification, Association Active, unrestricted Utilization Management Certification (CPHM). RN licensure preferred Nevada State Specific Requirements: Must be licensed currently or obtain licensure w/in 30 days of hire, for the state of Nevada. Nevada is not a compact state. WORK SCHEDULE : Mon - Fri / Sun - Thurs / Tues - Sat shift will rotate with some weekends and holidays. Training will be held Mon - Fri To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $27.73 - $54.06 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Utilization Review

Full-time

Care Review Clinician RN (BH Licensed)

apartment Molina Healthcare location_onLas Vegas, NV

$27.73 - $59.21 / HOUR

**Nevada residents preferred. Candidates who do not live in Nevada must be willing to work Pacific Business Hours . JOB DESCRIPTION Job Summary Provides support for member clinical service review processes specific to behavioral health. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations, and ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Assesses services for members - ensuring optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. • Analyzes clinical service requests from members or providers against evidence based clinical guidelines. • Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. • Conducts reviews to determine prior authorization / financial responsibility for Molina and its members. • Processes requests within required timelines. • Refers appropriate cases to medical directors and presents cases in a consistent and efficient manner. • Requests additional information from members or providers as needed. • Makes appropriate referrals to other clinical programs. • Collaborates with multidisciplinary teams to promote Molina care model. • Adheres to utilization management (UM) policies and procedures. • May work collaboratively with appropriate departments to provide applied behavior analysis (ABA)/behavioral health therapy (BHT) services to Molina members with autism spectrum disorder (ASD) and other related disorders. • May approve requests for BHT by reviewing behavioral assessments and treatment plans for medical necessity and BHT best practice guidelines. This includes but is not limited to: psychological evaluation requests, comprehensive diagnostic evaluations, functional behavioral assessments, and progress reports. • May perform ongoing monitoring of BHT treatment plans to evaluate effectiveness and treatment efficacy. • May provide peer to peer consultation BHT in-network providers to support treatment planning and maximize member progress. • May work collaboratively with ABA providers to ensure best service practices for members. • May create and develops forms, recommendations and guidelines and training for BHT service delivery. • May collaborate and coordinate with behavioral health medical directors, and senior medical directors to ensure proper management of the BHT benefit. Required Qualifications • At least 2 years health care experience, including experience in behavioral health and/or hospital acute care, or equivalent combination of relevant education and experience. • Licensed Clinical Social Worker (LCSW), Licensed Professional Counselor (LPC), Licensed Professional Clinical Counselor (LPCC), Licensed Marriage and Family Therapist (LMFT) or equivalent behavioral health licensure. License must be active and unrestricted in state of practice. • May require behavioral analyst experience, and/or board certification/licensure as a behavioral analyst (BCBA and/or LBA). • Demonstrated knowledge of community resources. • Ability to operate proactively and demonstrate detail-oriented work. • Ability to work within a variety of settings and adjust style as needed - working with diverse populations, various personalities and personal situations. • Ability to work independently, with minimal supervision and demonstrate self-motivation. • Responsive in all forms of communication, and ability to remain calm in high-pressure situations. • Ability to develop and maintain professional relationships. • Excellent time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change. • Excellent problem-solving, and critical-thinking skills. • Strong verbal and written communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications Certified Professional in Healthcare Management (CPHM). Recent hospital experience in an intensive care unit (ICU) or emergency room. ASAM Certification for behavioral health Previous experience with MCG guidelines. At least 2 years of experience with inpatient concurrent review, prior authorization and managed care; Acute care hospital experience with discharge planning and critical thinking skill set. Knowledge with Nevada Medicaid State rules and regulations (Medicaid Service Manual, billing guidelines, Provider Types, fee schedules) Ability to handle change in fast paced environment Team player with positive attitude for success Preferred License, Certification, Association Active, unrestricted Utilization Management Certification (CPHM). RN licensure preferred Nevada State Specific Requirements: Must be licensed currently or obtain licensure w/in 30 days of hire, for the state of Nevada. Nevada is not a compact state. WORK SCHEDULE : Mon - Fri / Sun - Thurs / Tues - Sat shift will rotate with some weekends and holidays. Training will be held Mon - Fri To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $27.73 - $59.21 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.