Posting ID: JP-002075093
• Reviews for information needed to make a medical necessity determination. Requests additional clinical information when needed to render a decision and determines next steps.
Must have some post-acute care experience and knowledge of InterQual and processing reviews
• Using clinical expertise, reviews clinical information and clinical criteria to determine if the service/device meets medical necessity for the patient.
• Ensure case review and elevation to complete the determination is rendered within the contractual and regulatory turnaround time standards to meet both contractual and regulatory requirements.
• Interact with the Medical Director as needed to ensure proper medical necessity decisions are being made in a timely manner.
• Acts as a clinical resource to department care coordinators, providing expertise and clinical support.
• Manages multiple tasks, is detail oriented, responsive, and demonstrate independent thought and critical thinking.
• Reviews and adheres to all Company policies and procedures and the Employee Code of Conduct.
LPN, licensed practical nurse, McKesson, InterQual, MCG, milliman, Managed care
Top Skills Details:
InterQual and Milliman experience a must. Experience working in concurrent Review, or utilization management. Commercial, Medicare or Medicaid experience preferred.
Must be used to working in a fast-paced environment
It doesn't require the fastest typers but must understand how to use computers and work basic MS Office products and the like.
Additional Skills & Qualifications:
• Associate's Degree or Diploma in Nursing/Practical Nursing required
• Must be a Registered Nurse/LPN/LVN or RT with Licensure in the state(s) of practice (based on allowable state practice act) is required during time of employment.
• Current and unrestricted license required.
• Minimum of 2 years of experience in a clinical setting required.
• Broad knowledge of health care delivery/managed care regulations, contract terms/stipulations, prior utilization management/review experience, and governmental home health agency regulations preferred.
• Excellent negotiation, communication, problem solving and decision making skills also preferred.
We know that a company's success starts with its employees. We also know that an individual's success starts with the right career opportunity. As a Best of Staffing® Client and Talent leader, Aerotek's people-focused approach yields competitive advantage for our clients and rewarding careers for our contract employees. Since 1983, Aerotek has grown to become a leader in recruiting and staffing services. With more than 250 non-franchised offices, Aerotek's 8,000 internal employees serve more than 300,000 contract employees and 18,000 clients every year. Aerotek is an Allegis Group company, the global leader in talent solutions. Learn more at Aerotek.com.
The company is an equal opportunity employer and will consider all applications without regards to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.
Recruiter: Jean Chambers
Phone: (410) 579-3072