Registered Nurse (Medical Services)
Location:
San Antonio , Texas
Posted:
February 08, 2017
Reference:
1263154349










This position is to support the Network Inpatient Initiatives to improve our member's transition and outcomes throughout the inpatient care process. The position will have the below main functions:
1. This position will allow for a more flexible response to increased work volume, staffing challenges and improved discharge and transition of care planning. Network Nurse Case Manager covers duty assignments as directed for various IPA's. Coverage assignments are directed to assist with new Medical Management Network Inpatient Initiatives across the Network along with cover of nurse case managers who are on PTO, leave, or assigned other temporary duties etc...
Network Nurse Case Manager covers duty assignments as directed for various IPA's. Coverage assignments are directed to cover nurse case managers who are on PTO, leave, assigned other temporary duties etc. Most assignments are temporary and are directed to support multiple IPA staffing needs. Duties are relegated to fill in for Concurrent Review Case Managers at local Acute Hospitals, Skilled Nursing Facilities and Pre-Certification Authorization/referral review Nurse duties. Assignments can be either in a hospital setting or at the IPA/Medical Group Office. **Under the prior experience below if candidate has strong experience in only one area will consider for position.
Qualifications
Ø CA Licensed RN or LVN
Ø 1 - 2 years managed care experience
Ø 1 plus years nursing experience in an Acute Hospital setting (Med/Surg, Tele, ICU) or like setting.
Ø Willingness to work at various job sites dependent on Network needs

Needed Prior Experiences
Ø Ability to perform concurrent review case management of patients in an Acute or SNF setting (utilization/clinical review and discharge planning)
Ø Ability to perform prior authorization/referral case management duties in the managed care setting (Specialty MD referrals, DME/Injectables referrals, Surgery Procedure referrals)


What are the hours? ( Training hours?) Work hours generally 8:30 am to 5 pm. No weekends. Training is dependent on prior experience, maybe 1 - 2 week. Trying to find persons who already have this skill set and just need to learn our process.
Will you be interviewing (face to face or phone) likely phone screens only, possible face to face if needed
Please confirm the worksite location - Various location dependent on need. Like out float case managers











Resource Type







Non IT Contractor








What Segment will this Contractor(s) Support?







OptumHealth








Is this position for TriCare related work, and if yes, what pay grade equivalency?







No - This position is not TriCare related








If this is Tricare related, does this position require National Agency Check (NAC) clearance?







No








Minimum Education Requirement







Highschool/GED or equivalent










Position involved in functions such as utilization management, medical case management, medical directors, nurseline, pharmacy management, quality management, etc. which require advanced medical training i.e. MD,RN, LPN, etc.
Primary Responsibilities:
• Performs utilization review activities, including pre-certification, concurrent, and retrospective reviews according to guidelines.
• Determines medical necessity of each request by applying appropriate medical criteria to first level reviews and utilizing approved evidenced based guidelines/criteria.
• Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services.
• Answers Utilization Management directed telephone calls; managing them in a professional and competent manner
• Refers case to a review physician when the treatment request does not meet necessity per guidelines, or when guidelines are not available. Referrals must be made in a timely manner, allowing the review physician time to make appropriate contact with the requesting provider in accordance with departmental policy and within CMS or URAC mandated turn around times.
• Reviews, documents, and communicates all utilization review activities and outcomes including, but not limited to, all calls made and received in regard to case communication and all demographic and service group information. Sends appropriate system-generated letters to provider and member.
• May provide guidance and coaching to other utilization review nurses and participate in the orientation of newly hired utilization nurses.
• Identify and refer all potential quality issues to the Clinical Quality Management Department, and suspected fraud and abuse cases to Compliance Department.
• Conducts rate negotiation with non-network providers, utilizing appropriate reimbursement methodologies.
• Documents rate negotiation accurately for proper claims adjudication.
• Identify and refer potential cases to Disease Management and Case Management.
• Performs all other related duties as assigned.

Qualifications
To be considered for this position, applicants need to meet the qualifications listed in this posting.
Required Qualifications:
• Current RN license, applicable for practice in the applicable state
• 2 years of experience in managed care OR 5 years of nursing experience as an RN
• Strong problem solving and analytical skills.
• Proficient in PC software computer skills.
• Excellent communication skills both verbal and written skills.
• Ability to interact productively with individuals and with multidisciplinary teams.
• Possess planning, organizing, conflict resolution, negotiating, and essential interpersonal skills.
Preferred Qualifications:
• Previous Prior Authorization experience
• Utilization Review/Management experience
• ICD-10, CPT coding knowledge/experience
• InterQual or Milliman Knowledge/experience


What are the hours? ( Training hours?) 1 shift 8 AM-5 PM, 1 shift 830 AM-530 PM, 1 shift 9AM-6PM
Will you be interviewing (face to face or phone)both- I can screen over the phone, but would like to meet them face to face for the interview.
Please confirm the worksite location - all postings are for onsite at 5800 Northwest Parkway, San Antonio TX 78249- there is no option to work at home.




Resource Type





Non IT Contractor




What Segment will this Contractor(s) Support?





OptumCare




Is this position for TriCare related work, and if yes, what pay grade equivalency?





No - This position is not TriCare related




If this is Tricare related, does this position require National Agency Check (NAC) clearance?





No




Minimum Education Requirement





Associates Degree


If you are interested please send your resume to Anthony at anthony.williams@adeccona.com or cal me at 925-349-0308










A little about us:
We partner with people to improve skills, teams and lives every day, and we help them achieve more than they ever thought possible.

Know someone who would be interested in this job? Share it with your network.