Job Title: Remote Utilization Management Case Manager
Pay: $37.16 an hr | Bi-weekly
Job Type:
• Remote
• Active RN License (AZ or Compact) — must be unrestricted.
• This position is a contract assignment with potential to hire on permanently based upon attendance, performance, and business needs
Shift Options:
• Monday–Friday, 8:30 AM–5:00 PM (AZ Time)
Remote Utilization Management Case Manager Overview:
• - Examines the appropriateness and medical necessity of requested healthcare services, such as hospital admissions, procedures, tests, and therapies.
- Applies in-depth knowledge of clinical guidelines, protocols, and evidence-based criteria to assess the necessity and quality of healthcare services.
- Research opportunities to optimize resource utilization, mitigate unnecessary procedures or tests, and promote the use of cost-effective alternatives.
- Provides education and guidance, under close supervision, to healthcare providers regarding utilization management processes, guidelines, and documentation requirements.
- Reviews medical records, analyzes clinical data, and determines if services align with established guidelines and standards.
- Communicates with healthcare providers, insurance companies, and other stakeholders to determine the need for prior authorization of certain healthcare services.
- Conducts routine reviews to monitor the ongoing care of patients during their hospital stay and/or treatment.
- Develops programs that promote quality effectiveness of healthcare services and optimize benefit utilization.
- Completes clinical reports that communicate findings, monitor key performance indicators, and track the effectiveness of utilization management initiatives.
Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program.
Applies critical thinking and knowledge in clinically appropriate treatment, evidence-based care, and medical necessity criteria for appropriate utilization of services.
Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.
Gathers clinical information and applies the appropriate medical necessity criteria/guideline, policy, procedure, and clinical judgment to render coverage determination/recommendation/discharge planning along the continuum of care.
Utilizes clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members.
Coordinates/Communicates with providers and other parties to facilitate optimal care/treatment.
Identifies members who may benefit from care management programs or other post discharge programs and facilitates referrals.
Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization.
Remote
About the Company:
A-Line Staffing Solutions LLC
A-Line Staffing Solutions is a premier staffing company that supplies professionals to the Healthcare, Insurance, Pharmaceutical, and Information Technology industries. Founded in 2004, A-Line Staffing Solutions has been a leader in matching talented individuals to the jobs that our clients NEED to fill. We are experts at offering creative staffing solutions to employers, and we are hiring every day. A-Line Staffing can offer short-term, long-term and direct-hire opportunities to professionals across the United States. We hire only the most qualified and talented individuals in the country. Our recruiting, selection and stringent screening processes have strengthened our reputation for delivering quality customer service and unbeatable talent. For our commissioned clients, A-Line Staffing closely follows the standards and practices established by The Joint Commission. For all of our clients and employees, our commitment to continual improvement combined with a strict code of ethics provides an atmosphere of respect and unparalleled professionalism. To find out how A-Line Staffing Solutions can share our talent with you, please contact us today. We are eager to include you among our most valued and satisfied clients. If you are a professional and would like to learn more about open opportunities in your area, please contact us today. We are always searching for talented and enthusiastic professionals
Company Size:
1,000 to 1,499 employees
Industry:
Staffing/Employment Agencies
Founded:
2004
Website:
http://www.alinestaffing.com/
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