Sorry, this job is no longer accepting applications. See below for more jobs that match what you’re looking for!

Concurrent Review Nurse II

Expired Job

Centene Corporation Columbia , SC 29209

Posted 3 months ago

Position Purpose: Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to emergent/urgent and continued stay reviews.

Perform onsite review of emergent/urgent and continued stay requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations

Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings

Collaborate with various staff within provider networks and discharge planning team electronically, telephonically, or onsite to coordinate member care

Conduct discharge planning

Educate providers on utilization and medical management processes

Provide clinical knowledge and act as a clinical resource to non-clinical team staff

Enter and maintain pertinent clinical information in various medical management systems

Direct care to participating network providers

Participate in utilization management committees and work on special projects related to utilization management as needed

For New Hampshire and Massachusetts - home visits required

Education/Experience: Graduate from an Accredited School of Nursing.

Bachelor's degree in Nursing preferred. 2 years of clinical nursing experience and 1 years of utilization management experience in a managed care setting. Acute care experience preferred. Knowledge of utilization management principles and healthcare managed care.

Experience with medical decision support tools (i.e. Interqual, NCCN) and government sponsored managed care programs

Licenses/Certifications: Current state's LPN/LVN or RN license.

For New Hampshire and Massachusetts - must obtain current state's RN license within 90 days of hire. Valid driver's license.

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

See if you are a match!

See how well your resume matches up to this job - upload your resume now.

Find your dream job anywhere
with the LiveCareer app.
Download the
LiveCareer app and find
your dream job anywhere

Boost your job search productivity with our
free Chrome Extension!

lc_apply_tool GET EXTENSION

Similar Jobs

Want to see jobs matched to your resume? Upload One Now! Remove
Hedis Review Nurse


Posted Yesterday

VIEW JOBS 12/15/2018 12:00:00 AM 2019-03-15T00:00 <strong>HEDIS® Review Nurse (RN or LPN) - Managed Care</strong><br /> Columbia, SC<br />   <div style="text-align: center;"><strong>*** This is a Full Time, Benefits Available, CONTRACT opportunity,<br /> expected to last the HEDIS season, meaning through May of 2019! ***</strong></div> <br /> <br /> <b>HEDIS Nurse Job Summary:</b> <ul> <li style="padding: 0; margin: 0;">The HEDIS Nurse coordinates and performs onsite data collection and data entry.</li> <li style="padding: 0; margin: 0;">The sole purpose of this position is for HEDIS chart abstraction, data collection and related activities, as assigned.</li> <li style="padding: 0; margin: 0;">The HEDIS Nurse is responsible for complete and accurate medical record review of charts collected from provider offices and the abstraction of critical data from medical records received via fax, mail, or electronic means for all HEDIS measures for the senior population.</li> </ul> <b>HEDIS Nurse Background:</b> <ul> <li style="padding: 0; margin: 0;">Valid, unrestricted state nursing license (R.N. or L.P.N.).</li> <li style="padding: 0; margin: 0;">Possess 1 season of recent experience in HEDIS data abstraction; experience must be from the last 3-5 years.</li> <li style="padding: 0; margin: 0;">Ability to review and extract significant data from medical records.</li> <li style="padding: 0; margin: 0;">Knowledge and experience of medical terminology, and medical record systems.</li> <li style="padding: 0; margin: 0;">Knowledgeable of the Health Plan Employer Data Information Set (HEDIS), as well as standards and reporting requirements for Medicare, Medicaid, and applicable state plans.</li> <li style="padding: 0; margin: 0;">Must be computer literate and knowledgeable in MS Office, E-mail and EMR systems, and multiple additional programs including word processing, and data management.</li> <li style="padding: 0; margin: 0;">Strong working knowledge of EZ-CAP preferred.</li> <li style="padding: 0; margin: 0;">Possess superior verbal and written communication skills, able to interface with business and medical professionals.</li> <li style="padding: 0; margin: 0;"><b>Must be willing and able to travel to area provider offices, as needed.</b></li> </ul> <b>® “HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).”<br /> <br /> <br /> #Clinical</b><br />   Carenational Columbia SC

Concurrent Review Nurse II

Expired Job

Centene Corporation