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Remote Utilization Review Nurse - Part Time
|Company:||Convergent||Location:||Boca Raton, Florida, United States|
|Posted:||Thursday, October 19, 2017|
Remote Part Time Temp position: 20-25 hours per week!
- Works with company’s Attorneys and Claims Representatives to overturn claims denied by Medicare, Medicaid, and other third-party payers based upon medical necessity and other clinical reasons.
- Reviews physician and medical documentation for appropriateness of hospitalization in order to support medical necessity and level of care appeals.
- Prepare and submit appeals to third party payers
- Remain current on applicable UR trends and regulations
- Provide ongoing training and feedback to company’s non-clinical staff members
- Perform other related duties as required
- Licensed RN –license must be active, and in good standing.
- Two to five years of Utilization Review experience in Managed Care or Hospital Case Management, Quality Assurance, Discharge Planning or other cost management programs preferred.
- Experience/Knowledge in all clinical areas, such as Cardiology, Pediatrics, Medical Surgical, Trauma and E.R., Cancer, Behavioral Health
- Experience using InterQual criteria or Milliman criteria required.
- Experience reviewing clinical polices and guidelines, i.e. NCD/LCD coverage documents, carrier specific policies related to investigational or experimental procedures.
- Experience in an acute care hospital required. (this can be hospital-based case management either from onsite at a hospital, or on the insurance side doing hospital reviews)
- Strong problem solving and decision making skills essential.
- Strong typing and computer skills essential.
- Excellent verbal and written communication skills; ability to speak clearly and convey complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others.
- Team Player - works well as a member of a group
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