Remote Utilization Review RN Case Manager Job at A-Line Staffing Solutions, Woonsocket, RI

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  • A-Line Staffing Solutions
  • Woonsocket, RI

Job Description

Job Description

Job Description

Job Title: Remote Utilization Review RN Case Manager

Pay: $34.13 an hr | Bi-weekly

Job Type:

  • Remote

Shift Options:

  • M-F 8-5

Remote Utilization Review RN Case Manager Overview:

  • 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.

  • Reports audit or clinical findings to appropriate staff or others in order to ensure appropriate outcome and/or follow-up for improvement as indicated.

Remote Utilization Review RN Case Manager Qualifications:

  • RN with current unrestricted state licensure or “multi-state privilege” compact nursing license.
  • 3+ years of clinical experience
  • 2+ years’ experience using personal computer, keyboard navigation, navigating multiple systems and applications; and using MS Office Suite applications (Teams, Outlook, Word, Excel, etc.)
  • Compact/Multi-state RN licensure is a plus
  • Emergency/critical care experience
  • Experience working member grievances/complaints
  • Case Management or Utilization Management experience
  • Managed care experience
  • Medicaid experience
  • Behavioral Health experience
  • Systems experience: ATV, ASD, GPS, MedCompass, QNXT, and Dynamo
  • Experience working with Regulatory Agencies
  • Critical thinking skills
  • Previous experience working in a remote/virtual environment.

Remote Utilization Review RN Case Manager Benefits:

  • Benefits are available to full-time employees after 90 days of employment and include health, optical, dental, life, and short-term disability insurance.
  • A 401(k) with a company match is available for full-time employees with 1 year of service on our eligibility dates.

How to Apply:

If you are interested in this position, please apply OR submit your resume to:

Saw Hlaing | shlaing@alinestaffing.com | 412-790-5425

Job Tags

Remote job, Full time, Temporary work, Shift work,

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