Job Information
US Tech Solutions Licensed Practical Nurse in Columbia, South Carolina
Job Description:
Timings- 8.00 am – 4.30 pm, Monday-Friday. Onsite interviews if local. Contract only.
Onsite for the first week to learn basics and wait for equipment to be prepared. The position is fully remote after that.
Preferred/Nice To Have skill sets/qualities: I would love to have someone with prior insurance/utilization review experience but I know that is not very common. A good candidate would have a diverse background with some knowledge of home health or DME as that is the type of cases they will most likely be working on. Strong computer skills are essential.
The nurse would work remotely from their home reviewing authorization requests from providers for home health visits or DME (durable medical equipment).
Requests are reviewed using the individual patient’s benefits contract and our medical policies. The nurse would read through clinical information, ensuring that all requirements are met based on contract and policy. Cases that do not meet requirements are sent on to an MD for review.
Nurses will interact daily with providers, teammates, and our MDs by phone and text. (Nurses are expected to meet productivity standards set for our area. New nurses are given time to work up to this, but should be showing improvement the longer they are here.)
Our team is knowledgeable and work well together. All have been here over 2 years and are invested in making this a good place to work. Due to the turnaround times required for each line of business, we all work together to get cases finished. If someone is not doing their part, it can be felt by the entire team. We all share our knowledge freely and try to make everyone feel comfortable asking for help when it is needed.
Responsibilities:
Performs medical reviews using established criteria sets and/or performs utilization management of professional, inpatient or outpatient, facility benefits or services, and appeals.
Documents decisions using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices.
May provide any of the following in support of medical claims review and utilization review practices: Performs medical claim reviews and makes a reasonable charge payment determination. Monitors process's timeliness in accordance with contractor standards.
Performs authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines. Utilizes allocated resources to back up review determination.
Reviews interdepartmental requests and medical information in a timely/effective manner in order to complete utilization process.
May conduct/perform high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs.
Performs screenings/assessments and determines risk via telephone. Reviews/determines eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services.
Provides education to members and their families/caregivers. Reviews first level appeal and ensures utilization or claim review provides thorough documentation of each determination and basis for each. Conducts research necessary to make thorough/accurate basis for each determination made.
Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
Responds accurately and timely with appropriate documentation to members and providers on all rendered determinations. Participates in quality control activities in support of the corporate and team-based objectives. Participates in all required training.
Experience:
- 2 years of Clinical experience.
Ceritfication:
- Active, unrestricted LPN/LVN licensure from the United States and in the state of hire.
Skills
Working knowledge of word processing software. Good judgment skills. Demonstrated customer service and organizational skills. Demonstrated proficiency in spelling, punctuation, and grammar skills.
Analytical or critical thinking skills. Ability to handle confidential or sensitive information with discretion. Ability to remain in a stationary position and operate a computer.
Required Software and Tools: Microsoft Office.
Education:
- Associate Degree - Nursing or Graduate of Accredited School of Nursing
About US Tech Solutions:
US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit www.ustechsolutions.com (http://www.ustechsolutionsinc.com) .
US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity,
national origin, disability, or status as a protected veteran.