Registered Nurse

Day to Day:60% Provides active case management, assesses service needs, develops and coordinates action plans in cooperation with members, monitors services and implements plans, including member goals. Evaluates outcomes of plans, eligibility, level of benefits, place 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 that consist of intensive assessment/evaluation of condition, at-risk education based on members’ identified needs, and member-centered coaching utilizing motivational interviewing techniques in combination with reflective listening and readiness-to-change assessment to elicit behavior change and increase member program engagement. 20% Performs medical or behavioral review/authorization process. Ensures coverage for appropriate services within 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 flow and proper claims adjudication. Demonstrates compliance with all applicable legislation and guidelines for all regulatory bodies, which may include but is not limited to ERISA, NCQA, URAC, DOI (State), and DOL (Federal). 10% Participates in direct intervention/patient education with members and providers regarding healthcare delivery systems, utilization of networks, and benefit plans. May identify, initiate, and participate in on-site reviews. Serves as member advocate through continued communication and education. Promotes enrollment in care management programs and/or health and disease management programs. 5% Maintains current knowledge of contracts and network status of all 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. 5% Provides appropriate communications (written and telephone) regarding requested services to both healthcare providers and members. Job Requirements: Required Skills and Abilities: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 make sound decisions. 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. Required Education: Associate Degree in Nursing, OR Graduate of an Accredited School of Nursing, OR Master's Degree in Social Work (for Div. 6B or Div. 75), OR Master's Degree in Psychology or Counseling (for Div. 75 only). Required Experience: 4 years recent clinical experience in a defined specialty area (oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, or general medicine/surgery), OR 4 years utilization review, case management, clinical experience, or a combination thereof; 2 of the 4 years must be clinical. Required License/Certificate:Active, unrestricted RN license from the United States and in the state of hire, OR active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), OR active, unrestricted licensure as a Social Worker from the United States and in the state of hire (Div. 6B), OR active, unrestricted licensure as a Counselor or Psychologist from the United States and in the state of hire (Div. 75 only). For Div. 75 and Div. 6B, except for CC 426: URAC-recognized Case Management Certification must be obtained within 4 years of hire as a Case Manager. Preferred Education: Bachelor's Degree in Nursing. Preferred Work Experience: 7 years of healthcare program management experience. Preferred Licenses and Certificates: Case Manager Certification and clinical certification in specialty area. Applicant Notices & Disclaimers For information on benefits, equal opportunity employment, and location-specific applicant notices, click here At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position's starting pay is: $37.00/hr. Show more Show less