Description: We are seeking a RN Licensed in CA for a Case Manager RN REMOTE position!
Job Details: Job title: Case Mgr Rn
Location: Fully remote
Work type: Contract
Job overview:
Responsible for the review and evaluation of specialty injectable 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.
This job will have the following 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 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.
Qualifications & Requirements:
Requires an RN with unrestricted active license.
Managed Care required.
Medicare experience required.
Prior Authorization required.
Pharmacy prior authorization required
Contact: eturner@judge.com
This job and many more are available through The Judge Group. Find us on the web at www.judge.com
