nurse reviewer

Expertise Forge Connections Pvt. Ltd.

<p><b>Job title: Physician Reviewer</b><br/><b>Schedule: M-F(8-5)</b><br/><b>Contract: 2+ Years</b><br/><b>Pay rate: $105/Hour on W2</b></p><p><b>Description:</b></p><ul><li>This position requires an initial time commitment of at least 4 weeks to undergo and complete training.</li><li>After training, physician medical reviewer will provide weekend coverage, 8-hour shifts per Saturday and/or Sunday per month. Goal productivity of at least 32 cases per weekend day. This is a remote position.</li><li>Physician medical reviewer evaluates clinical service requests based on company guidelines to make medical necessity determinations.</li></ul><p><b>Required Qualification(s): </b></p><ul><li>Must be board Certified, M.D. or D.O with an unrestricted physician license in a state or territory of the United States.</li><li>Must demonstrate basic computer skills.</li></ul><p>Job Type: Contract</p><p>Pay: $100.00 - $105.00 per hour</p><p>Expected hours: 40 per week</p><p>Benefits:</p><ul><li>Dental insurance</li><li>Health insurance</li><li>Paid time off</li><li>Referral program</li><li>Travel reimbursement</li><li>Vision insurance</li></ul><p>Work Location: Remote</p>

Physician Reviewer

Accenture

<p><b>Skill required:</b> Claims Appeals - Claims Administration<br>
<b>Designation:</b> Health Admin Services New Associate<br>
<b>Qualifications:</b>Any Graduation
<br>
<b>Years of Experience:</b>0 to 1 years
<br>
<b>About Accenture</b><br>
Accenture is a global professional services company with leading capabilities in digital, cloud and security.Combining unmatched experience and specialized skills across more than 40 industries, we offer Strategy and Consulting, Technology and Operations services, and Accenture Song&mdash; all powered by the world&rsquo;s largest network of Advanced Technology and Intelligent Operations centers. Our 699,000 people deliver on the promise of technology and human ingenuity every day, serving clients in more than 120 countries. We embrace the power of change to create value and shared success for our clients, people, shareholders, partners and communities.Visit us at www.accenture.com
<br>
<b>What would you do?</b> To provide support to the clinical team and client team to assist in the promotion of quality member outcomes, to optimize member benefits, and to promote effective use of resources. Supports the procedures that ensure adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective. Utilization Management: Gathers information using the appropriate client-specific telephonic screening tools. Conducts pre-review screening under the guidance and direction of US licensed health professionals. Case Management/Disease Management -Provides support functions for wellness programs, health management programs and preventative care opportunities that the member may have as part of their benefits. Gathers information using the appropriate client-specific telephonic screening tools.<br>
<b>What are we looking for?</b> &bull;Microsoft Excel &bull;Microsoft PowerPoint &bull;Written and verbal communication &bull;Related outsourcing operations experience &bull;Claims reviews/audit experience and data entry experience &bull;Knowledge of utilization management process and ability to interpret and apply member contracts, and member benefits &bull;Knowledge of ICD-9 and ICD-IO and CPT codes, preferred &bull;Experience in medical or insurance field, preferred &bull;Requires solving of routine problems, largely through precedent and referral to general guidelines. &bull;Interaction is within own team and direct supervisor &bull;Requires analysis and solving of increasingly complex problems. &bull;Interaction is with peers within Accenture before updating supervisors. Likely has some interaction with clients and/or Accenture management. With proper guidance and oversight by Team Lead, may be tapped for precepting, training, mentoring and job shadowing duties &bull;Holds current and unrestricted local (PH) Registered Nurse license. &bull;Bachelor of Science Nursing (BSN) degree &bull;Excellent written and verbal communication skills in English &bull;Must pass American English and alternate language fluency test (&quot;Test&quot;) upon hire (non-US resident) by successfully completing internal written test. For voice accounts, you must pass US Berlitz B2 level or Versant score 58 and above upon hire or upon assuming role. &bull;Proficiency in basic computer knowledge with the ability to learn additional computer programs &bull;A minimum of three (3) months of prior working experience as a Registered Nurse in a clinical setting required o Three months is equivalent to 480 hours of working experience as an RN o Work experience as a Registered Nurse means holding an active RN license and providing direct patient care o Clinical setting includes inpatient hospital, outpatient hospital or clinic, or 1-year related Accenture or other outsourcing experience or returning Analyst employee &bull;Strong customer service focus o Ability to empathize o Prioritizing customer needs
<br>
<b>Roles and Responsibilities:</b> &bull;Manages incoming or outgoing telephone calls, e-Reviews, and/or faxes, including triage, opening of cases and data entry into client system. &bull;Determines contract; verifies eligibility and benefits. &bull;Conducts a thorough provider radius search in client system and follows up with provider on referrals given. &bull;Checks benefits for facility-based treatment. &bull;Obtains intake (demographic) information from caller, e-Reviews, and/or from fax. Processes incoming requests, collection of non-clinical information needed for review from providers, utilizing scripts to screen basic and complex requests for pre-certification and/or prior authorization. &bull;Performs data entry of contact into client systems and routes as appropriate Match fax/clinical records with appropriate case. &bull;Consolidate inputs for approval. &bull;Generate the needed letters as directed by client and/or outlined in client s procedure manual &bull;Assign cases/activities and work within client s system to facilitate workflow and productivity goals. &bull;Refers cases requiring clinical review to a nurse reviewer. Performs case checks and reviews to ensure case creation is complete, correct, and &quot;nurse ready&quot;. &bull;Tasks cases accurately to the correct queue. &bull;Conducts outbound scripted calls to providers to request clinical information as directed by clinician. &bull;Conducts outbound scripted calls to providers to complete approval notification process as directed by clinician. &bull;Performs Daily Task list maintenance activities under the direction of the Team Lead/Operations Manager and as per customer workflow. &bull;Provide administrative support to /Nurse Reviewer via case preparation, phone number verification, medical record requests and verbal call out approval notifications. &bull;Provide administrative support of post service claims utilizing the member s benefit contract and health plan guidelines. &bull;Performs administrative tasks and work as directed by clinician or Team Lead/Operations. Consults clinician and Team Lead/Operations Manager timely and appropriately. &bull;Reports inventory numbers and assigns task lists under the direction of the Team Lead/Operations and as requested by the customer. &bull;Prioritize follow-up and actions based on case request receipt dates, customer workflow, service level agreements and regulatory timeframes. &bull;Responsibilities exclude collection of non-scripted information, evaluation, or interpretation of clinical information, and providing medical advice/opinion on treatment or services. &bull; Please note that this role may require you to work in rotational shifts</p>
<br>
Any Graduation

Health Admin Services New Associate

Acentra Health

<div>Company Overview:
<div>
Acentra Health exists to empower better health outcomes through technology, services, and clinical expertise. Our mission is to innovate health solutions that deliver maximum value and impact.</div><div></div><div><br>
Lead the Way is our rallying cry at Acentra Health. Think of it as an open invitation to embrace the mission of the company; to actively engage in problem-solving; and to take ownership of your work every day. Acentra Health offers you unparalleled opportunities. In fact, you have all you need to take charge of your career and accelerate better outcomes &ndash; making this a great time to join our team of passionate individuals dedicated to being a vital partner for health solutions in the public sector.</div>
Job Summary and Responsibilities:
<div><b>
Acentra Health is looking for a Clinical Reviewer (SCA) to join our growing team.</b></div><div><b><br>
Job Summary:</b></div><div></div><div><br>
The purpose of this position is to utilize clinical expertise during beneficiary interaction and determine appropriateness for advocacy intervention in conjunction with contract requirements, critical thinking and utilize decision-making skills to assist with communicating determine medical appropriateness, while maintaining production goals and QA standards. Ensures day-to-day processes are conducted in accordance with NCQA and other regulatory standards.</div><div></div><div><b><br>
Responsibilities:</b></div><ul><li>
Assures accuracy and timeliness of all applicable review type cases within contract requirements</li><li>
Assesses, evaluates, and addresses daily workload and queues; adjusts work schedules daily to meet the workload demands of the department</li><li>
In collaboration with Supervisor, responsible for the quality monitoring activities including identifying areas of improvement and plan implementation of improvement areas</li><li>
Maintains current knowledge base related to review processes and clinical practices related to the review processes, functions as the initial resource to nurse reviewers regarding all review process questions and/or concerns</li><li>
Functions as providers&rsquo; liaison and contact/resource person for provider customer service issues and problem resolution</li><li>
Performs all applicable review types as workload indicates</li><li>
Fosters positive and professional relationships and act as liaison with internal and external customers to ensure effective working relationships and team building to facilitate the review process</li><li>
Attends training and scheduled meetings and for maintenance and use of current/updated information for review</li><li>
Cross trains and perform duties of other contracts to provide a flexible workforce to meet client/customer needs</li><li>
Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.</li></ul><p><b><i>
*This position will be 25 hours/week*</i></b></p><p></p><div><i><br>
The list of accountabilities is not intended to be all-inclusive and may be expanded to include other education- and experience-related duties that management may deem necessary from time to time.</i>
</div>Qualifications:
<div><b>
Required Qualifications</b></div><ul><li>
Active unrestricted LPN, RN or, Social Worker or other applicable State and/or Compact State clinical license</li><li>
Minimum three years of clinical experience in an acute or med-surgical environment</li><li>
Strong clinical assessment and critical thinking skills required</li><li>
Medical record abstracting skills required</li><li>
Excellent written and verbal communication skills</li><li>
Must be proficient in Microsoft Office and Internet/web navigation</li></ul><div><b>
Preferred Qualifications</b></div><ul><li>
Bachelor&rsquo;s Degree from an accredited college or university in a related field</li><li>
Some knowledge of Case Management, UR and/or Prior Authorization or related experience</li><li>
Experience in a behavioral health setting</li><li>
Bilingual</li></ul><div><b>
Why us?</b></div><div></div><div><br>
We are a team of experienced and caring leaders, clinicians, pioneering technologists, and industry professionals who come together to redefine expectations for the healthcare industry. State and federal healthcare agencies, providers, and employers turn to us as their vital partner to ensure better healthcare and improve health outcomes.</div><div></div><div><b><br>
We do this through our people.</b></div><div></div><div><br>
You will have meaningful work that genuinely improves people's lives across the country. We are a company that cares about our employees, and we give you the tools and encouragement you need to achieve the finest work of your career.</div><div></div><div><b><br>
Benefits</b></div><div></div><div><br>
Benefits are a key component of your rewards package. Our benefits are designed to provide you with additional protection, security, and support for both your career and your life away from work. Our benefits include comprehensive health plans, paid time off, retirement savings, corporate wellness, educational assistance, corporate discounts, and more.</div><div></div><div><b><br>
Thank You!</b></div><div></div><div><br>
We know your time is valuable and we thank you for applying for this position. Due to the high volume of applicants, only those who are chosen to advance in our interview process will be contacted. We sincerely appreciate your interest in Acentra Health and invite you to apply to future openings that may be of interest. Best of luck in your search!</div><div></div><div><br>
~ The Acentra Health Talent Acquisition Team</div><div></div><div><br>
Visit us at https://careers-acentra.icims.com</div><div></div><div><b><br>
EEO AA M/F/Vet/Disability</b></div><div></div><div><br>
Acentra Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, national origin, disability, status as a protected veteran or any other status protected by applicable Federal, State or Local law.</div><div></div><div><b><br>
Compensation</b></div><div></div><div><br>
The pay range for this position is listed below.</div><div></div><div><br>
&ldquo;Based on our compensation philosophy, an applicant&rsquo;s position placement in the pay range will depend on various considerations, such as years of applicable experience and skill level.&rdquo;</div>
Pay Range: USD $28.00 - USD $33.00 /Hr.</div>

Clinical Reviewer (Remote - SCA - 25 Hrs/Wk)

EXL Service

<p>Associate - Nurse (BSc)</p><p>Basic Function</p><p>Facilitate the delivery of applicable benefits that are reasonably and appropriately billed, which in turn promotes cost effective outcomes for all the members who require our services.</p><p>Essential Functions</p><p>Responsible for the review and evaluation of the services being appealed based on the available information and medical policy</p><ul><li>Reviews documentation and evaluates whether the services performed were appropriate based on clinical policies and guidelines</li><li>Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation.</li><li>Data gathering requires navigation through multiple system applications.</li><li>Commands a comprehensive knowledge of complex delegation arrangements, contracts (member and provider), clinical criteria, benefit plan structure, regulatory requirements, company policy and other processes which are required to support the review of the clinical documentation/information.</li><li>Pro-actively and consistently apply the regulatory and accreditation standards to ensure that activities are reviewed and processed within guidelines.</li><li>Condenses complex information into a clear and precise clinical picture</li><li>Independently prepares a clinical summary for medical doctor review and provides a recommendation whenever necessary</li><li>Work requires the ability to perform close inspection of handwritten and computer-generated documents as well as a PC monitor.</li></ul><p>Education Requirements</p><ul><li>India Registered Nurse with an active license (BSc Nurse)</li></ul><p>Work Experience Requirements</p><ul><li>2 years of Clinical Experience</li><li>Practical experience in the nursing field: hospital, industrial, community, outpatient and clinical</li></ul><p>Job Type: Full-time</p><p>Benefits:</p><ul><li>Health insurance</li><li>Paid sick time</li><li>Provident Fund</li></ul><p>Ability to commute/relocate:</p><ul><li>Kochi, Kerala: Reliably commute or planning to relocate before starting work (Preferred)</li></ul><p>Education:</p><ul><li>Bachelor's (Required)</li></ul><p>Experience:</p><ul><li>Clinical : 2 years (Required)</li></ul><p>Shift availability:</p><ul><li>Night Shift (Required)</li></ul><p>Work Location: In person</p>

Associate Nurse

West Coast University

<p>At American Career College, we share a<em> passion for students and transforming healthcare education!</em> As an associate for a certified Great Place to Work, you will join a collaborative, student-centric culture valuing academic integrity, mutual respect, student learning, service, responsiveness, innovation, diversity, and stewardship. As a part of this team, you will guide students to do more than change their own lives - you will help change the lives of every patient they care for throughout their career. At American Career College, you will have the opportunity to share your expertise and passion with the next generation of nurses.</p><p><strong>You will make an impact by: </strong></p><ul><li>Providing each nursing program(s) with the necessary Assessment Technologies Institute (ATI) management and oversight to help each cohort achieve or exceed ACC's outcomes. Benchmarking 90% of each graduating cohort to achieve the green light and the program.</li><li>Achieving a 90% or better first-time pass rate on the NCLEX each quarter.</li><li>Collaborating with the Director of Nursing (DON), overseeing a comprehensive success plan that evaluates the effectiveness of ATI initiatives, creating new methods to improve specific ATI student/graduate and faculty performance.</li><li>Developing/implementing administrative systems and procedures to monitor and improve ATI effectiveness and provides analysis and remediation strategies to help ensure students/graduates are actively engaged in their ATI program and that graduates pass NCLEX with a satisfactory level of performance on their first attempt.</li><li>Serving as the campus ATI champion to support both existing students and graduates until NCLEX is passed.</li></ul><p><strong>Your Experience Includes:</strong></p><ul><li>A minimum of at least one (1) year's previous experience with program management.</li><li>Knowledge in technological support and delivery of educational programs and services.</li><li>Knowledge and evidence of strong management skills, and administrative systems management as applicable to specialized program area.</li><li>Knowledge of state, federal and local laws/regulations relating to programs, governmental compliance, and other regulatory standards such as ABHES, BVNPT, BRN, and other accreditation standards.</li><li>Experience: ATI product experience.</li><li>A minimum of one to two years of professional testing and/or statistical data experience involving database management.</li><li>Experience working with nursing programs.</li><li>Experience with Blackboard Learning Management System.</li><li>Experience with Campus Vue.</li></ul><p><strong>Education:</strong></p><ul><li>Bachelor's degree from an accredited college or university that includes course work in education or business administration OR equivalent experience required.</li><li>Master's degree in nursing preferred.</li></ul><p><strong>Licenses/Certifications: </strong></p><ul><li>Current vocational nurse or registered nurse licensed required. Must meet faculty requirements.</li></ul><p></p><b>Campus: </b>ACC Orange County Campus La Palma<br><b>Function: </b>Faculty<img src="https://www.jobg8.com/Tracking.aspx?kf3pjJbFAb%2bWnE9H4ZPj0YhrF3w6vbzGb" width="0" height="0" />

Assistant Director of NCLEX Review

<p><b>Skill required:</b> Claims Appeals - Claims Administration<br>
<b>Designation:</b> Health Admin Services Associate<br>
<b>Qualifications:</b>Any Graduation
<br>
<b>Years of Experience:</b>1 to 3 years
<br>
<b>About Accenture</b><br>
Accenture is a global professional services company with leading capabilities in digital, cloud and security.Combining unmatched experience and specialized skills across more than 40 industries, we offer Strategy and Consulting, Technology and Operations services, and Accenture Song&mdash; all powered by the world&rsquo;s largest network of Advanced Technology and Intelligent Operations centers. Our 699,000 people deliver on the promise of technology and human ingenuity every day, serving clients in more than 120 countries. We embrace the power of change to create value and shared success for our clients, people, shareholders, partners and communities.Visit us at www.accenture.com
<br>
<b>What would you do?</b> To provide support to the clinical team and client team to assist in the promotion of quality member outcomes, to optimize member benefits, and to promote effective use of resources. Supports the procedures that ensure adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective. Utilization Management: Gathers information using the appropriate client-specific telephonic screening tools. Conducts pre-review screening under the guidance and direction of US licensed health professionals. Case Management/Disease Management -Provides support functions for wellness programs, health management programs and preventative care opportunities that the member may have as part of their benefits. Gathers information using the appropriate client-specific telephonic screening tools.<br>
<b>What are we looking for?</b> &bull;Microsoft Excel &bull;Microsoft PowerPoint &bull;Written and verbal communication &bull;Related outsourcing operations experience &bull;Claims reviews/audit experience and data entry experience &bull;Knowledge of utilization management process and ability to interpret and apply member contracts, and member benefits &bull;Knowledge of ICD-9 and ICD-IO and CPT codes, preferred &bull;Experience in medical or insurance field, preferred &bull;Requires analysis and solving of increasingly complex problems. &bull;Interaction is with peers within Accenture before updating supervisors. Likely has some interaction with clients and/or Accenture management. With proper guidance and oversight by Team Lead, may be tapped for precepting, training, mentoring and job shadowing duties &bull;Holds current and unrestricted local (PH) Registered Nurse license. &bull;Bachelor of Science Nursing (BSN) degree &bull;Excellent written and verbal communication skills in English &bull;Must pass American English and alternate language fluency test (&quot;Test&quot;) upon hire (non-US resident) by successfully completing internal written test. For voice accounts, you must pass US Berlitz B2 level or Versant score 58 and above upon hire or upon assuming role. &bull;Proficiency in basic computer knowledge with the ability to learn additional computer programs &bull;A minimum of three (3) months of prior working experience as a Registered Nurse in a clinical setting required o Three months is equivalent to 480 hours of working experience as an RN o Work experience as a Registered Nurse means holding an active RN license and providing direct patient care o Clinical setting includes inpatient hospital, outpatient hospital or clinic, or 1-year related Accenture or other outsourcing experience or returning Analyst employee &bull;Strong customer service focus o Ability to empathize o Prioritizing customer needs
<br>
<b>Roles and Responsibilities:</b> &bull;Manages incoming or outgoing telephone calls, e-Reviews, and/or faxes, including triage, opening of cases and data entry into client system. &bull;Determines contract; verifies eligibility and benefits. &bull;Conducts a thorough provider radius search in client system and follows up with provider on referrals given. &bull;Checks benefits for facility-based treatment. &bull;Obtains intake (demographic) information from caller, e-Reviews, and/or from fax. Processes incoming requests, collection of non-clinical information needed for review from providers, utilizing scripts to screen basic and complex requests for pre-certification and/or prior authorization. &bull;Performs data entry of contact into client systems and routes as appropriate Match fax/clinical records with appropriate case. &bull;Consolidate inputs for approval. &bull;Generate the needed letters as directed by client and/or outlined in client s procedure manual &bull;Assign cases/activities and work within client s system to facilitate workflow and productivity goals. &bull;Refers cases requiring clinical review to a nurse reviewer. Performs case checks and reviews to ensure case creation is complete, correct, and &quot;nurse ready&quot;. &bull;Tasks cases accurately to the correct queue. &bull;Conducts outbound scripted calls to providers to request clinical information as directed by clinician. &bull;Conducts outbound scripted calls to providers to complete approval notification process as directed by clinician. &bull;Performs Daily Task list maintenance activities under the direction of the Team Lead/Operations Manager and as per customer workflow. &bull;Provide administrative support to /Nurse Reviewer via case preparation, phone number verification, medical record requests and verbal call out approval notifications. &bull;Provide administrative support of post service claims utilizing the member s benefit contract and health plan guidelines. &bull;Performs administrative tasks and work as directed by clinician or Team Lead/Operations. Consults clinician and Team Lead/Operations Manager timely and appropriately. &bull;Reports inventory numbers and assigns task lists under the direction of the Team Lead/Operations and as requested by the customer. &bull;Prioritize follow-up and actions based on case request receipt dates, customer workflow, service level agreements and regulatory timeframes. &bull;Responsibilities exclude collection of non-scripted information, evaluation, or interpretation of clinical information, and providing medical advice/opinion on treatment or services. &bull; Please note that this role may require you to work in rotational shifts</p>
<br>
Any Graduation

Health Admin Services Associate

Accenture in India

<div>
 <strong>
  Skill required:
 </strong>
 Claims Appeals - Claims Administration
 <br/>
 <br/>
 <strong>
  Designation:
 </strong>
 Health Admin Services Associate
 <br/>
 <br/>
 <strong>
  Qualifications:
 </strong>
 Any Graduation
 <br/>
 <br/>
 <strong>
  Years of Experience:
 </strong>
 1 to 3 years
 <br/>
 <br/>
 <strong>
  About Accenture
  <br/>
  <br/>
 </strong>
 Accenture is a global professional services company with leading capabilities in digital, cloud and security.Combining unmatched experience and specialized skills across more than 40 industries, we offer Strategy and Consulting, Technology and Operations services, and Accenture Song&mdash; all powered by the world&rsquo;s largest network of Advanced Technology and Intelligent Operations centers. Our 699,000 people deliver on the promise of technology and human ingenuity every day, serving clients in more than 120 countries. We embrace the power of change to create value and shared success for our clients, people, shareholders, partners and communities.Visit us at www.accenture.com
 <br/>
 <br/>
 <strong>
  What would you do?
 </strong>
 To provide support to the clinical team and client team to assist in the promotion of quality member outcomes, to optimize member benefits, and to promote effective use of resources. Supports the procedures that ensure adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective. Utilization Management: Gathers information using the appropriate client-specific telephonic screening tools. Conducts pre-review screening under the guidance and direction of US licensed health professionals. Case Management/Disease Management -Provides support functions for wellness programs, health management programs and preventative care opportunities that the member may have as part of their benefits. Gathers information using the appropriate client-specific telephonic screening tools.
 <br/>
 <br/>
 <strong>
  What are we looking for?
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Microsoft Excel
  </li>
  <li>
   Microsoft PowerPoint
  </li>
  <li>
   Written and verbal communication
  </li>
  <li>
   Related outsourcing operations experience
  </li>
  <li>
   Claims reviews/audit experience and data entry experience
  </li>
  <li>
   Knowledge of utilization management process and ability to interpret and apply member contracts, and member benefits
  </li>
  <li>
   Knowledge of ICD-9 and ICD-IO and CPT codes, preferred
  </li>
  <li>
   Experience in medical or insurance field, preferred
  </li>
  <li>
   Requires analysis and solving of increasingly complex problems.
  </li>
  <li>
   Interaction is with peers within Accenture before updating supervisors. Likely has some interaction with clients and/or Accenture management. With proper guidance and oversight by Team Lead, may be tapped for precepting, training, mentoring and job shadowing duties
  </li>
  <li>
   Holds current and unrestricted local (PH) Registered Nurse license.
  </li>
  <li>
   Bachelor of Science Nursing (BSN) degree
  </li>
  <li>
   Excellent written and verbal communication skills in English
  </li>
  <li>
   Must pass American English and alternate language fluency test ("Test") upon hire (non-US resident) by successfully completing internal written test. For voice accounts, you must pass US Berlitz B2 level or Versant score 58 and above upon hire or upon assuming role.
  </li>
  <li>
   Proficiency in basic computer knowledge with the ability to learn additional computer programs
  </li>
  <li>
   A minimum of three (3) months of prior working experience as a Registered Nurse in a clinical setting required o Three months is equivalent to 480 hours of working experience as an RN o Work experience as a Registered Nurse means holding an active RN license and providing direct patient care o Clinical setting includes inpatient hospital, outpatient hospital or clinic, or 1-year related Accenture or other outsourcing experience or returning Analyst employee
  </li>
  <li>
   Strong customer service focus o Ability to empathize o Prioritizing customer needs Roles and Responsibilities:
  </li>
  <li>
   Manages incoming or outgoing telephone calls, e-Reviews, and/or faxes, including triage, opening of cases and data entry into client system.
  </li>
  <li>
   Determines contract; verifies eligibility and benefits.
  </li>
  <li>
   Conducts a thorough provider radius search in client system and follows up with provider on referrals given.
  </li>
  <li>
   Checks benefits for facility-based treatment.
  </li>
  <li>
   Obtains intake (demographic) information from caller, e-Reviews, and/or from fax. Processes incoming requests, collection of non-clinical information needed for review from providers, utilizing scripts to screen basic and complex requests for pre-certification and/or prior authorization.
  </li>
  <li>
   Performs data entry of contact into client systems and routes as appropriate Match fax/clinical records with appropriate case.
  </li>
  <li>
   Consolidate inputs for approval.
  </li>
  <li>
   Generate the needed letters as directed by client and/or outlined in client s procedure manual
  </li>
  <li>
   Assign cases/activities and work within client s system to facilitate workflow and productivity goals.
  </li>
  <li>
   Refers cases requiring clinical review to a nurse reviewer. Performs case checks and reviews to ensure case creation is complete, correct, and "nurse ready".
  </li>
  <li>
   Tasks cases accurately to the correct queue.
  </li>
  <li>
   Conducts outbound scripted calls to providers to request clinical information as directed by clinician.
  </li>
  <li>
   Conducts outbound scripted calls to providers to complete approval notification process as directed by clinician.
  </li>
  <li>
   Performs Daily Task list maintenance activities under the direction of the Team Lead/Operations Manager and as per customer workflow.
  </li>
  <li>
   Provide administrative support to /Nurse Reviewer via case preparation, phone number verification, medical record requests and verbal call out approval notifications.
  </li>
  <li>
   Provide administrative support of post service claims utilizing the member s benefit contract and health plan guidelines.
  </li>
  <li>
   Performs administrative tasks and work as directed by clinician or Team Lead/Operations. Consults clinician and Team Lead/Operations Manager timely and appropriately.
  </li>
  <li>
   Reports inventory numbers and assigns task lists under the direction of the Team Lead/Operations and as requested by the customer.
  </li>
  <li>
   Prioritize follow-up and actions based on case request receipt dates, customer workflow, service level agreements and regulatory timeframes.
  </li>
  <li>
   Responsibilities exclude collection of non-scripted information, evaluation, or interpretation of clinical information, and providing medical advice/opinion on treatment or services.
  </li>
  <li>
   Please note that this role may require you to work in rotational shifts, Any Graduation
   <br/>
  </li>
 </ul>
</div>


Search 2659+ Nurse reviewer jobs near you this October. New roles added regularly across leading industries. Apply today.

2659 nurse reviewer jobs NEAR_ME

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