Overview:   

Perform prospective, concurrent and retrospective review of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, intensity of service and level of care, including appeal requests initiated by providers, facilities and members.  May establish care plans and coordinate care through the health care continuum including member outreach assessments.

RESPONSIBILITIES/TASKS:

• Review, research and authorize requests for authorization of elective, direct, ancillary, urgent, emergency, etc. services. Contact appropriate medical and support personnel to identify and recommend alternative treatment, service levels, length of stays, etc. using approved clinical protocols.
• Analyze, research, respond to and prepare documentation related to retrospective review requests and appeals in accordance with local, state and federal regulatory and designated accreditation (e.g. NCQA) standards.
• Establish, coordinate and communicate discharge planning needs with appropriate internal and external entities.
• Analyze patterns of care associated with disease progression; identify contractual services and organize delivery through appropriate channels.
• Research and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, Mental Health, Substance Abuse care coordination, etc.
• Identify and document quality of care issues; resolve or route to appropriate area for resolution.
• Follow out-of-area/out-of-network services and make recommendations on patient transfer to in-network services and/or alternative plans of care.
• Develop and deliver targeted education for provider community related to policies, procedures, benefits, etc.
• As needed and in conjunction with Provider Services, may identify and negotiate reimbursement rates for non-contracted providers for services.
• Other duties may be assigned based on designated department assignment.

This position description identifies the responsibilities and tasks typically associated with the performance of the position.  Other relevant essential functions may be required.

EMPLOYMENT QUALIFICATIONS:

EDUCATION:

Bachelor’s degree in nursing, allied health, business, or related field preferred. Registered Nurse with current unrestricted Registered Nurse license required. Certification in Case Management may be preferred based upon designated department assignment. 

EXPERIENCE:

Minimum two (2) years of clinical experience which may include acute patient care, discharge planning, case management, and utilization review, etc.  Demonstrated clinical knowledge and experience relative to patient care and health care delivery processes. One (1) year health insurance plan experience or managed care environment preferred.

SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:

• Excellent written and verbal communication skills. Excellent customer service and interpersonal skills.
• Working knowledge of current industry Microsoft Office Suite PC applications.
• Ability to apply clinical criteria/guidelines for medical necessity, setting/level of care and concurrent patient management.
• Knowledge of current standard medical procedures/practices and their application as well as current trends and developments in medicine and nursing, alternative care settings and levels of service.
• Knowledge of applicable accreditation standards, local, state and federal regulations.
• Other related skills and/or abilities may be required to perform this job based upon designated department assignment.

Geographic Responsibility:  Remote, US

Type of Employment: Full-time, permanent 

FLSA Classification (USA Only): Exempt 

Work Environment: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job:  

• The employee is occasionally required to move around the office. Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception, and ability to adjust focus.  

• Work across multiple time zones in a hybrid or remote work environment. 

• Long periods of time sitting and/or standing in front of a computer using video technology. 

• May require travel dependent on company needs. 

The above statements are intended to describe the general nature and level of the job being performed by the individual(s) assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required. HealthEdge reserves the right to modify, add, or remove duties and to assign other duties as necessary. In addition, reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position in compliance with the Americans with Disabilities Act of 1990.  Candidates may be required to go through a pre-employment criminal background check. 

HealthEdge is an equal opportunity employer. We are committed to workforce diversity and actively encourage all qualified persons to seek employment with us, including, but not limited to, racial and ethnic minorities, women, veterans and persons with disabilities. 

#LI-Remote 

**The annual US base salary range for this position is $50/hr. This salary range may cover multiple career levels at HealthEdge. Final compensation will be determined during the interview process and is based on a combination of factors including, but not limited to, your skills, experience, qualifications and education.